Category: Reflection

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Consult-Liaison Nonfiction Reflection

Doors and Ducks.

Three people were standing outside of his apartment. His voice was muffled, though it was clear that he had no intention of opening his door. One person recrossed his arms; this group of young staff had already spent about 15 minutes trying to persuade him to open his door.

I offered to try; they obliged. In less than 60 seconds, he opened his door, showed his face, and greeted me with warmth.

Their face masks did not conceal their surprise.

This is how I did it. I:

  • read many books that describe different ways to listen and talk to people
  • watched many people (professionals and otherwise) talk to other people (patients or otherwise) and stole successful strategies
  • received and incorporated feedback from teachers who watched and listened to me talk to people
  • sat through hours of watching videotapes of myself talking to other people
  • have spent literally years talking to people who often did not want to talk to me

They didn’t see:

  • the many, many errors I have made in trying to connect with people
  • patients telling me directly how my approach was offensive and disrespectful
  • that one time someone threw a shoe at me because I wouldn’t leave him alone
  • the many times patients said nothing to me despite all my efforts to encourage them to talk to me
  • all the times I said something stupid that ruined any rapport we had
  • the times patients have yelled at me to leave because I didn’t respect their requests
  • that other time when the guy in the wheelchair literally rolled out of his room at high speed to get away from me (and I couldn’t find him anywhere on that floor in the hospital)
  • the variety of insults I have received (and will continue to receive) from people for reasons both valid and invalid

They also did not realize that:

  • luck played a large role in this outcome
  • the clinical relationship I have with him is different from the relationships they have with him (i.e., to him, I am novel)
  • I have been doing this sort of work for many more years than they have
  • I still consider everyone my teacher and continue to learn from them all
  • they can and will learn skills to achieve similar outcomes in the future

Now that winter is upon us, ducks called Barrow’s Goldeneye have arrived in Puget Sound. Sometimes a male and female swim together as an isolated pair; sometimes a flock of 10 to 20 ducks will paddle around the piers.

They look serene while gliding across the surface of Sound. We don’t see their legs and feet constantly pushing against the water.

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Reflection

Hope for the Future.

It’s been over three months since I posted something here, though it feels right to write a few words here today.

Upon learning that Biden and Harris have won the Presidential election, my first thought was:

Thank God we will have a better Covid-19 response.

For all of us who have the privilege and responsibility to look after the health and well-being of others, the weight of the pandemic over the past few months has felt like it would grind us into dust, regardless of our efforts. I sustained a significant muscle strain in my back over a month ago and someone quipped, “Who doesn’t feel like the world is straining their back?”

Of course, a new administration won’t make the pandemic disappear. People will continue to get sick from Covid-19. Some will die. A federal administration, though, that takes the pandemic seriously will result in thoughtful planning, greater prevention efforts, and coordination that will directly impact those of us who are trying to prevent some of the most vulnerable in our communities from getting sick.

I am also thankful that I get to witness the first Black and Indian Vice President!

The upcoming days, weeks, and months will be noisy. As Trump continues to demonstrate low frustration tolerance and impulse control, his vitriol will become more hostile. He has been rewarded with the gifts of attention and validation for these behaviors for over five years now; these behaviors will amplify before they are extinguished. We can never truly get away from ourselves.

For those of us who have been lucky enough to have good health and safety, may this continue. May more and then all people be able to experience good health and safety as time continues to move forward.

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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?

Categories
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.

Categories
Homelessness Nonfiction Reflection Seattle

Remembering.

There were three shootings in a 25-hour period in Seattle this week. The third shooting occurred during rush hour. Multiple fire trucks raced past the lines of cars in the downtown grid; I remember thinking, “It must be a big fire.”

The newspaper later reported that the person who died in the third shooting was a woman who was previously homeless, but now had lived for nearly ten years in permanent housing. Based on her history of homelessness alone and the location of the shooting, some people might assume that she made an active choice to be there, that it was somehow her fault that she was shot. Would those people also assume that the others who were shot—including the nine year-old boy—made an active choice to be there, that they are to blame for getting shot?

There is now a vacancy in that apartment, and people will miss her.

Two days prior, I went to a homeless shelter with hopes of talking with a patient. He wasn’t there—maybe he was trying to avoid me; maybe he forgot; maybe he had more important things to do—but there was a makeshift memorial in the lobby.

As I made my way to the memorial, a man with fresh scabs all over his face and pants too big for his legs walked past. A woman with grey hair leaned forward and used her skinny legs to roll backwards in her wheelchair.

On the folding table was a grayscale image of a man’s face printed on a standard sheet of paper. The image was blurry due to the low resolution, but his smile was bright and clear. Next to this image was a large sheet of white butcher paper, along with some pens.

Several dozen people—other people staying in the shelter—had written messages on the butcher paper:

You went too soon, man.

I miss you and hope to see you again in heaven.

I hope it’s better where you are now.

Another person had already taken the bed that this deceased man previously occupied.

She was trying not to cry.

“It’s completely normal to feel sad when one of our [patients] die,” I said. “You were connected to him.”

A small laugh came out of her mouth, and then the tears fell from her eyes.

He wasn’t an old man, but he wasn’t a spring chicken, either. He didn’t like to stay in the shelters; sometimes other men would call him names or make fun of the way he talked. He slept under a bridge, though came into the clinic several times a week. He and I had only met once; he was courteous, made small jokes, and called me “ma’am”. I wished that he would stop smoking methamphetamine. He wished for that, too.

She, his case manager, was hopeful. They talked about his health; they worked on applications to help him get into housing so he didn’t have to stay in a shelter or sleep outside; they talked about how methamphetamine was getting in the way of what he wanted.

“I wasn’t prepared for this sense of loss,” she said, wiping her face. “We talked about his plans. I was hopeful that things would change for him.”

A few weeks prior, he was sitting across from me in that office. She and I now sat there, our sadness filling the room.

I have a friend, also a psychiatrist, who works in a prison. She has commented that these individuals—people living on the streets, people in jails and prisons, people who are part of marginalized and excluded populations—are considered “throwaways”, that people don’t think about them, that they are the forgotten ones.

We only forget about them if we forget that they’re people, just like us.