Category: Reading

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Policy Reading

The Word “Mental” in Project 2025. (i)

The word “mental” appears 16 times in “Mandate for Leadership: The Conservative Promise”, better known as Project 2025.

It first appears in the foreword on page 4, under the first promise to “restore the family as the centerpiece of American life and protect our children”:

Today, the American family is in crisis. Forty percent of all children are born to unmarried mothers, including more than 70 percent of black children. There is no government program that can replace the hole in a child’s soul cut out by the absence of a father. Fatherlessness is one of the principal sources of American poverty, crime, mental illness, teen suicide, substance abuse, rejection of the church, and high school dropouts. So many of the problems government programs are designed to solve—but can’t—are ultimately problems created by the crisis of marriage and the family. The world has never seen a thriving, healthy, free, and prosperous society where most children grow up without their married parents. If current trends continue, we are heading toward social implosion.

Let’s take a closer look at this with a critical eye:

Yes, according to the CDC, in 2022, about 40% of all children in the US were born to unmarried women. Let’s be charitable and assume that the author made a rounding error: Just under 70% of these “nonmarital births” occurred in Black women. For what reason did he highlight the percentage for Black women? The percentage for American Indian and Alaska Native women was about 68%. The second lowest percentage was among White women, which was just over 27%.

It is beyond the scope of my expertise to remark if fatherlessness is “one of the principal sources of American poverty, crime… rejection of the church, and high school dropouts”, but I can comment on “mental illness, teen suicide, [and] substance abuse”.

(A quick skim of data, though, shows that “Christian women in the U.S. are more religious than their male counterparts” and “women are more likely than men to say they attend worship services regularly”. From this data it seems that fathers are more likely to reject the church.)

This paper from 2013, The Causal Effects of Father Absence from the Annual Review of Sociology, tries to correct for flaws of past studies that tried to discern what happens to kids when their fathers are absent. From their work the authors conclude there is:

  • strong evidence that father absence negatively affects children’s social-emotional development, particularly by increasing externalizing behavior (where “externalizing behavior” means aggressive and attention-seeking behavior, in contrast to “internalizing behavior”, which manifests as anxiety and depression)
  • strong evidence that father absence increases adolescents’ risky behavior, such as smoking or early childbearing
  • [some suggestion] that the psychological harms of father absence experienced during childhood persist throughout the life course

Again, let’s be generous towards the author and assume that he equated “externalizing behavior”, “internalizing behavior”, and “risky behavior” to “mental illness[es]”. (Behaviors alone do not always constitute mental illnesses.) Yes, research supports the idea that an absent father results in behavioral problems in children. However, fatherlessness itself may not be a “principal source”. I could not find robust studies that examined any relationship between motherlessness and mental illness. (Single mothers are far more common than single fathers. Motherless children may exhibit these same worrisome behaviors.)

I am not able to find data that directly links absent fathers to teen suicides in the US. (There is a paper that describes “parental absence predicts suicide ideation through emotional disorders” in China, though this doesn’t focus solely on absent fathers. A paper from the US in 1998 concludes that “dramatic increase in youth suicide during the past three decades seems unlikely to be attributable to the increase in divorce rates”.) If there is an indirect linkage, it is likely mediated by other factors that led to the absence of the father.

While it is true that no governmental program can “replace the hole in a child’s soul cut by the absence of a father”, it is not only the absence of a father that cuts holes in children’s souls. No program, whether offered by the government or a church, can replace a missing father, mother, or other parental figure. Programs are not people. So let’s talk about actual people.

Over two-thirds of children live with married parents. The nonmarital birthrate continues to decrease over time. Divorce rates are also decreasing. In light of these facts, that “fatherlessness” is actually decreasing, what “crisis of marriage and the family” and pending “social implosion” is the author talking about?

The authors of Project 2025 do not seem to recognize what the authors of “The Causal Effects of Father Absence” declare: “family disruption is not a random event and because the characteristics that cause father absence are likely to affect child well-being through other pathways.” (emphasis mine)

If they are concerned about “poverty, crime, mental illness, teen suicide, substance abuse, rejection of the church, and high school dropouts”, there are more fruitful ways to address these problems:

Reduce the likelihood that children experience adverse childhood events. People with fewer adverse childhood events are less likely to develop mental illnesses, like depression, and less likely to attempt or die by suicide. (Fathers can be sources of adverse childhood events. There is research that shows that youth with “harsher fathers” engaged in more offending behaviors and used more substances than youth with “absent fathers”. Sometimes, unfortunately, fatherlessness is the better option.)

Promote health equity. Improving physical environments where people live, work, and play improves mental health and well-being, as does access to education. People want to work and learn in healthful spaces. Reducing income equality also improves physical and mental health. People want enough money to live in safety and comfort. Ensure that people have easy access to health care when they need it, but, even better, create a healthy nation where people won’t need to routinely see a doctor.

Promote social connections to reduce loneliness. People who are socially isolated are more likely to develop physical illnesses, such as heart disease and diabetes, as well as mental illnesses, such as anxiety and depression.

Note that these interventions require looking beyond the immediate family, and certainly beyond the presence or absence of a father. We live in communities. Because we all live in an interdependent networks, if the community is experiencing crisis, it will impact families. So why does Project 2025 instead put so much focus on the father?

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Consult-Liaison Education Medicine Public health psychiatry Reading

What is Mental Health? (01)

To try to answer the perennial question I ask myself (“what am I doing?”), I recently read this 2015 article, What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey.

As a psychiatrist1, do I treat mental illness? What is mental illness? What is mental health?

The paper comments on the ambiguity in the definition of “mental health”:

Mental health can be defined as the absence of mental disease or it can be defined as a state of being that also includes the biological, psychological or social factors which contribute to an individual’s mental state and ability to function within the environment.

Upon reading this I recognized that I define “mental health” according to the second definition, “a state of being…”. This also explains why I internally bristle when people say “mental health” when they actually mean “mental illness”. (Example: The Lancet Commission on ending stigma and discrimination in mental health.)

Figure 2B, the Two Continua Model, resonates with me:

There are people with diagnoses of significant mental illnesses who have “high mental health”. (If we’re going to be picky about words, I’m not sure that I like grading mental health as “high” or “low”. Maybe “well” versus “unwell”? It is more common to hear “I’m physically doing well,” rather than “My physical health is high.”)

Consider the person with a diagnosis of schizophrenia who has been hospitalized multiple times in the past. However, now they go about their lives and only make contact with their healthcare team every few months for routine check-ins.2

Then there are people with no diagnosable mental illness who have “low mental health”. Consider the many people who felt psychologically unwell during the Covid pandemic.

I started doodling to try to determine where psychiatry should intervene along the axes of mental illness and mental wellness:

I have yet to come up with any convincing answers. This doodling did offer clarity, though:

My professional interest has been the diagnosing and treatment of (often severe) mental illness. There are many reasons for this. One compelling reason is that the severity of symptoms makes it unmistakable that professional intervention is warranted.3

Only after years had passed did I recognize that this worldview is why I chafed at some requests patients brought to me early in my career. I once went through an entire diagnostic interview with a guy who worked as a game designer. Nothing came up; according to the Two Continua Model, he had neither a mental illness nor low mental health. Only at the end did he reveal why he had sought care from a psychiatrist: “My girlfriend takes Prozac and it made her more creative. I thought that if I take Prozac, that might make me creative, too, which can help me with my work.”

My goal was to diagnose and treat a mental illness. His goal was mental enhancement.

Are these two goals mutually exclusive? I don’t think so, though I want to noodle on this more.

The history of psychiatry holds these two goals in tension, too: On one end are the state psychiatric hospitals (also called asylums) where some people with severe symptoms (or not) were held (warehoused?) prior to the elimination of these institutions. On the other end are the psychoanalysts, where the typical patient was “a college-educated, upper-middle class professional who paid for service out of pocket.”

More to follow as I continue to wonder what I am doing.

  1. It was never part of The Plan to become a psychiatrist. This is part of the reason why I ask myself the perennial question, “What am I doing?”
  2. When asked, “What is your best life?”, no one responds, “I want to spend as many precious moments of my existence in hospitals and clinics.”
  3. A choice quote from the paper that highlights why I personally like clarity about where professional intervention is warranted: “Lots of things can cause people problems—poverty, vices, social injustice, stupidity—a definition of health should not end up defining these as medical problems.”
Categories
Homelessness Reading

Down and Out, On the Road.

It took me a couple of months, but I finally got through Down and Out, On the Road: The Homeless in American History (first mentioned in this post). Here are the main points I took from the book:

“Down and Out” refers to people who live in impoverished urban areas. More specifically, people who live on “skid row” are “down and out”. (The term “skid row” likely originated in Seattle. As noted in both the Underground Tour and Beneath the Streets Tour in the Pioneer Square neighborhood, tree logs cut from the hills were pushed down Yesler Way towards the waterfront. Logs skidding down Yesler Way led to the name “skid row”.) These days, “skid row” typically refers to centers of poverty in cities where homeless people often reside. This is paired with…

“On the Road” refers to people who were homeless and, in trying to search for work, rode the trains. They often did not ride in the train, but rather on or under the train. These same individuals might reside in “down and out” areas upon arriving in a city. During the 1800s, people who were homeless were often associated with riding the rails than living in skid rows.

The term “the jungle” has been used to describe homeless encampments for nearly 200 years. In recent years here in Seattle, “the jungle” has referred specifically to a large encampment tucked under many trees in an undeveloped area near Interstate 5. This “jungle” was also notorious in the local press for violence (and was subsequently razed, though it seems that there are evergreen efforts to revive it). Over the past 200 years, people who had no place to live set up camp in forested areas (“jungles”) outside of urban centers, which developed into communities.

Cycles of romanticizing and vilifying homeless people are not new. People with no place to live are poor. Because the working class recognized how similar their struggles were with people who were homeless, they were (and continue to be) consistently more sympathetic, empathetic, and generous to them. Other classes, though, have swung between perceptions that people who are homeless are harmless—perhaps even charming (see Norman Rockwell) to lazy, deviant, and dangerous. (Other indicators include The Way It Is and Mr. Wendal, both excellent songs.)

Homelessness is a consequence of poverty. When I first received the book, I confess that I was dismayed to see in the index that “mental illness” is mentioned on only four pages of this ~250 page text. Kusmer, the author, provides a compelling historical account that various systems, including government policy (or lack thereof), economic forces, and cultural values are the chief drivers that lead to people becoming poor. Poverty is a major risk factor for homelessness. (I know this from my own anecdotal experience: Most people who are homeless do not have a severe psychiatric illness like schizophrenia. People often develop psychiatric symptoms because of homelessness. Even if every single psychiatrist in the nation worked with people who are homeless, homelessness would persist: There are plenty of people who are unhoused who do not need psychiatric treatment. They need a place to live and ways to have money to pay for living expenses.)

There was a federal program to address homelessness! Homelessness has been and continues to be a nationwide problem (regardless of the size of the US throughout time) that requires a federal response. The Federal Transient Service (FTS) was the first (and only?) federal agency in US history whose goal was to aid people who were homeless and unemployed. It started in 1933 and only lasted two years, in part because it seemed “successful”: The number of homeless people dropped, so everyone thought the problem of homelessness was solved. FTS funds were swept to support public works and Social Security. (In theory, public works and Social Security seemed like better investments to prevent homelessness.)

The disproportionate number of homeless people who are Black is not new. This is another legacy of slavery. A number of minority populations (e.g., Native Americans, Mexicans, women) suffer from homelessness because of policies and practices related to economic and class exclusion.

Down and Out, On the Road: The Homeless in American History was published in 2002. My sense is that the author, when viewing the current state of homelessness in the US, would continue to argue that the forces that contribute to poverty remain the primary driver of homelessness. I think he would continue to view mental illness and substance use as distractions and not significant causes of homelessness. (To be clear, I don’t think he’s discounting psychiatric conditions as contributors to homelessness for specific individuals, particularly since psychiatric conditions, both directly and indirectly, can pull people into poverty.) I appreciate how he ends the text:

The compulsion to stereotype the homeless as dependent and deviant turns the poorest Americans into an abstract “other,” separate and inferior from everyone else. Although their problems are more severe, however, destitute people living on the streets and in homeless shelters are not so different from the rest of us. They never have been. Any genuine effort to end homelessness must begin with a recognition of that essential truth.

Categories
Homelessness Reading Reflection

Words and Sounds.

The reason behind my recent silence here is I am attending to a beloved family member whose health continues to deteriorate. Surely other medical professionals have written about the difficulties of our roles and responsibilities: We are not (and should not be!) doctors or nurses for the ones we love, though it is difficult to push the professional knowledge out of our minds. Sometimes (often?) it doesn’t feel like love is enough, even as we realize that our professional knowledge isn’t enough, either.

I have spent most of my career working with people experiencing homelessness. I don’t recall newspapers and other media writing about this topic as much as they do now:

Homelessness is a federal problem. Was there ever a time when the feds tried to solve the problem of people having no place to live? What is the history of homelessness in the US?

Well, there’s actually a FREE, short paper (it’s an appendix!) from a long report about permanent supportive housing with the title “The History of Homelessness in the United States“. That article led me to the book Down and Out, On the Road: The Homeless in American History. I’m about 80 pages in and, so far, it’s not encouraging. The arguments and opinions about homelessness from 100 and 200 years ago are similar to what we hear now in 2023 (deserving vs. undeserving poor, work tests, etc.). I’m hoping the author will describe the intersections of homelessness (“vagrancy”) and health, including substance use (alcohol? opium?) and mental illness.

If this problem were easy to solve, we would have already solved it… right?

The inimitable Ed Yong is leaving The Atlantic! His stellar writing about Covid over the past three years were invaluable to me: Not only did he provide meaningful analysis about how Covid was affecting individuals and populations, but he also accurately captured the horror of what was happening.

In his recent newsletter, he shared the following:

… I want to double down on my journalistic values: not only describing what is happening but helping people actually make sense of it; bearing witness to suffering; speaking truth to power; revealing wonder in the obscure; and pushing for a more just and equitable world.

He has succeeded in adhering to his values (and received a well-deserved Pulitzer along the way). This has prompted me to consider what values I hold in my writing. (Are the values I hold in my professional role transferrable to my writing? Is writing part of my professional role? Why am I mincing my life into roles when they are interconnected, as per the first paragraph of this post?)

Let’s end this post with some lighter fare:

  • 15 Relaxing Mario Jazz Medley (just go listen)
  • If you’ve seen the Barbie movie: I know most people are fawning over the song “I’m Just Ken”, but “Push” is the underrated gem. I’ll never hear the word “granted” the same way again.

Categories
Reading Seattle

Recommendations.

Here’s a small selection of things I humbly recommend for your consideration:

The Disadvantages of an Elite Education. “Our best universities have forgotten that the reason they exist is to make minds, not careers.” (Incisive writing from William Deresiewicz, who is also the author of one of my favorite essays, Solitude and Leadership.)

Ice Merchants: A Father and Son’s Daring Cliff Dive. This is a beautiful, wordless animation that left me speechless.

Why Are These Italians Massacring Each Other With Oranges? Every winter, Ivrea erupts into a ferocious three-day festival where its citizens pelt one another with 900 tons of oranges. (Yes, oranges.) (Thoughtful, descriptive, and hilarious writing from Jon Mooallem.)

The Complete Maus: A Survivor’s Tale. I bought this book on a whim. I don’t understand why some schools have banned it—more people who read it.

E-Jae Pak Mor: These TikTok-Famous Dumplings Deserve the Hype. If you live in or around Seattle and if you like Thai food, give this place a try. (The owner and I met years ago when she was working as a cook at Turkish restaurant. E-Jae Pak Mor is her first restaurant—how thrilling it is to make your dream come true! This is Thai street food and it is delicious.)

Emmett Shear: “I’ll be 40 years old soon. I thought I’d take a look back and see how I’ve spent it….” (Includes a link to a spreadsheet so you can make your own.)