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.)
The Tacoma News Tribune graciously agreed to publish an opinion piece an esteemed fellow psychiatrist and I wrote. I invite you to read the 500-word essay, Crisis care centers are important. But WA needs more to fill behavioral health gaps, directly through the newspaper (and show a local newspaper some appreciation through page views!). The piece has particular relevance to residents in King County in Washington State.
If you have more time and would like to read the original version, you can find it below. Thanks for your interest.
King County voters will decide whether to fund a network of crisis care centers in April. There are many reasons to support this: We all know people who have experienced behavioral health crises, including kids in school; colleagues at work; family members; and people we encounter in the community.
Because King County currently has only one crisis center, additional centers will help. However, the entire behavioral health system in Washington is in crisis. A narrow focus on these centers only may lead to even more people tumbling into crisis.
King County has explained that these five crisis centers will “provide a safe place… specifically designed, equipped and staffed for behavioral health urgent care. These Centers will provide immediate mental health and substance use treatment and promote long-term recovery.”
If crisis centers have the most resources, they will be the most robust and responsive element of the system. Outpatient clinics providing earlier intervention and prevention services are often understaffed and have waitlists. People already enrolled in these clinics may wait weeks to months for follow-up appointments. Those leaving hospitals also compete for clinic appointments. This excessive waiting can precipitate crises. People should not have to be in crisis to access care.
Crisis care centers are designed to accept anyone, with or without insurance. Many behavioral health clinics have insurance restrictions. Some clinics don’t accept public insurances like Medicaid or Medicare. Others do, though have limited funds to provide services for uninsured people or for those ineligible to obtain insurance. Such restrictions will funnel uninsured people to the crisis centers. Yet, where will they go for ongoing care?
Due to limited resources, crisis care centers must screen and triage referrals. If people experiencing symptoms related to mental illness or substance use don’t meet criteria for admission to a crisis center or a hospital, what then? If under-resourced outpatient clinics remain understaffed or close, these individuals will be forced to wait for treatment. Their symptoms may worsen, precipitating preventable crises, which no one wants.
The option for people to stay up to 14 days in a crisis care center can help people connect to ongoing services. However, many agencies are unable to see people and establish care within 14 days, in part due to what King County described as: “The behavioral health workforce is strained under the magnitude of the need, all while being underpaid, overworked, and stretched too thin.”
The levy touts the use of peer counselors in crisis centers. Peers with lived experience are valuable, though should not be the primary providers of care. Peer counselors often have the lowest wages and, in some for-profit models, make up the bulk of personnel, presumably to maximize revenue. Some people in crisis are among the most vulnerable, ill, and complex patients in the region. Both patients and staff across the entire continuum of care deserve sufficient support and resources to get, and stay, out of crisis. If people experiencing mental health crises receive insufficient services, they are more likely to fall back into crisis and return to these centers. If these crisis centers are operated by for-profit organizations, readmissions will increase their revenue. We have already witnessed this pattern in several for-profit psychiatric hospitals where patients experienced harm. Patients and their families deserve better.
King County needs crisis centers, but personnel in other parts of the system also need support. The levy notes that funding for residential treatment facilities will focus on capital and maintenance. Building conditions are important, though the staff who work in these buildings are just as valuable. Many individuals receive ongoing care in residential treatment facilities following acute hospital treatment. Supporting and retaining staff in these residential programs are vital in reducing behavioral health crises.
Outpatient clinics with robust funding for personnel, technology, and other resources, along with appropriate reimbursement of services—things that never happened after the original deinstitutionalization movement of the 1960s—will help people access care. This, along with preventative efforts and early intervention at the first signs of behavioral health challenges, decreases crises.
Ultimately, supporting peoples’ basic needs will reduce the need for crisis centers. Living wages, affordable housing, access to food, universal health care coverage, employment opportunities, education and training, and building social connections, will reduce psychological burdens and promote wellness.
This levy should be viewed as an initial investment in improving our battered behavioral health care system. More needs to be done to improve the mental health of our friends, family, and neighbors.
(I know it’s the holiday season and I promise I’m not actually a grinch, but here’s your warning: This is going to be kind of a bummer of a post.)
Some recent scenes for your consideration:
The sliding wooden gate did nothing to dampen the sounds of traffic on the boulevard. Inside the wooden gate was a parking lot that was now occupied by around 40 small sheds, each painted a different color. At one end was an open-air shared kitchen and a set of small bathrooms. It was snowing, the kind of wet, clumpy snow that doesn’t stick, but instead seeps immediately into clothes, hats, and sleeping bags. Though people in this “village” are still technically homeless, they were at least protected from this unusual Seattle weather. Within a few minutes of my arrival, a skinny kid, maybe eight or nine years old, wearing a sweater, shorts, and sandals, ambled outside alone to look up at the sky. Later, another skinny kid, maybe thirteen or fourteen, came out, his hands shoved into the pockets of his sweatpants and his eyes fixed on the ground. I wondered what their ACEs scores were and hoped that, as adults, they would escape and remain out of homelessness.
As I threaded my way through the city and the morning chill, I kept a mental tally: One man wearing a tank top and making grand gestures at the sky; another shirtless man pacing in tight circles; one woman wearing a soiled hoodie, with either black ink or a black substance smeared across the bottom half of her face, picking up trash from water pooled in the gutter; a man hobbling with a cane and screaming a melody; a man emerging from a collapsed tent to fold up a crinkled black tarp; a woman with bare legs and swaths of bright green caked on her eyelids who, in slurred speech, offered me a wristwatch dangling from her fingers.
“We have burned down the house of mental health in this city, and the people you see on the street are the survivors who staggered from the ashes,” writes Anthony Almojera, an N.Y.C. Paramedic [who has] Never Witnessed a Mental Health Crisis Like This One, who also comments that “there’s a serious post-pandemic mental health crisis.”
Maybe my expectations about the pandemic response were too high. A pandemic is an act of God; what could mankind possibly do that can deter the power of God?
I do believe that hope is a discipline. It’s hard to practice every day. But this is why I still question whether my expectations were too high. God spared us—you, dear reader, and me—during this pandemic. For what reason? What can and should we do with the gifts of our lives?
The bus stop is at 145th Street and Aurora Avenue. There was a city bus there; if I run the two blocks fast enough, I thought, maybe I can catch it.
Then I noticed the two law enforcement vehicles, sturdy vans with red and blue lights flashing from the windows. One was parked directly in front of the bus; the other was in the driveway of a nearby storefront.
The bus remained at the stop as a third law enforcement vehicle made an assertive U-turn in the middle of the street to join the other two.
I stopped walking. I took a few steps forward, then stopped again.
“No, this doesn’t seem right… I can catch the bus at the next stop,” I muttered out loud.
It was a few minutes after 11am on Tuesday, November 8th, in the year of our Lord 2022.
There is essentially no sidewalk on the west side of Aurora Avenue. I reached the bus stop at 135th Street on Aurora; no bus was coming. I kept walking, squeezing myself between the parked cars and the businesses along the street. I had faith that a sidewalk would soon appear.
I heard the rumbling first. A bulky black box with thick treads on its large wheels approached. A man wearing a helmet and sunglasses inside the armored vehicle glanced out the open window. The red and blue lights in the front and on top of the vehicle were not on. The white “SWAT” lettering on its side gleamed in the late morning sunlight.
A few minutes later, a second armored SWAT vehicle rumbled past.
“What is happening?” I asked.
A photo of the 14-year-old was distributed to all Seattle police and an officer located the two teens on a Metro bus at North 145th Street and Aurora Avenue North at 11:02 a.m., the charges say.
I had to cut through a car dealership on Aurora because there still wasn’t a sidewalk. Despite the sun floating in the blue of the sky, I put the black beanie back on my head. Underneath my black wool winter coat was a black puffer jacket; a grey scarf was knotted around my neck. I continued to look for a sidewalk. I was apparently unwilling to cross the street.
The young women already knew that there is no sidewalk on Aurora, so they stood in the street. Their hands, adorned with colorful fingernails, tossed their shiny, long hair over their shoulders. Their shorts and skirts stopped just past the curvature of their hips, exposing the bare skin of their legs to the gaze of drivers and the cold morning air. The cropped jackets covered their arms, but not their cleavage. Their eyelashes looked like small, dark butterflies on their cheeks. Shades of red, pink, and purple were on their lips.
They weren’t yet waving at cars passing by.
One of them waved at me as I approached and called, “Hey!”
We made eye contact; she grinned. “What do you call those big cats that live in the hills?”
I reflexively smiled back at her, though did not stop walking. “Mountain lions?” I guessed.
Her rosy lips bloomed into a satisfied smile. She nodded, pointed at me, and said, “I like that.”
I shrugged and kept walking. I wished she and her peers weren’t standing out there. I wondered what their circumstances were. I prayed for their health and safety. I thought about why she asked me this peculiar question. (I only learned about REST, real escape from sex trafficking, after this conversation.)
I continued to look for a sidewalk.
About a week later, I boarded the light rail at the most northern stop. It was another sunny and cold day.
Many young people were on the train. Some of them had signs. I couldn’t read all of them; I spied one that was upside down that included the word “GUNS”.
They poured out of the train at Pioneer Square. Many of them had traveled over 130 blocks to join other students at Seattle City Hall to
[call] for better mental health support, more restrictions on gun access and more training for security staff in the wake of a shooting Tuesday at Ingraham High that left one student dead.
The rains have finally returned to Seattle, though the wildfires continue to burn:
Wildfires from Google Maps as of the morning of 2022 Oct 24.
That map does not include the entirety of Washington State (there are more fires outside the boundaries of that image), or the fires burning in neighboring Idaho and Oregon.
While we did not experience the blood red skies that San Francisco experienced from the wildfires of the summer of 2020, the air was looked and smelled thick. Each whiff contained fragrant notes of Douglas Fir and perhaps Western Red Cedar, all overwhelmed by charred carbon. Landmarks disappeared into a gritty haze of grey. The evenings featured a crimson sun sinking into ashy layers of peach, pink, and coral.
By October 19th, Seattle had the worst air quality on the planet:
Conditions did not improve the next day. The Space Needle has a webcam (more precisely a “panocam”, as it provides a 360-degree view). Go take a look at it now; this is the grey pall that we embrace for much of the year. Despite this pewter drape, one can still see the surrounding buildings, lakes, and trees. Compare this to the view on October 20th:
(“Is the Mountain Out?” refers to glorious Mt. Rainier, the 14,410-foot tall stratovolcano that looms over the region.)
The rain finally arrived on October 21 and displaced the smoke:
In addition to headaches, congestion, and watery eyes, people also experience psychological effects due to wildfires. I came across this paper in Nature Human Behavior from July 2022 that reports on one aspect of this: Exposures and behavioural responses to wildfire smoke (no paywall as of this writing). While the paper doesn’t quite answer the question I want to answer, it did report:
… during large wildfire smoke events, individuals in wealthy locations increasingly search for information about air quality and health protection, stay at home more and are unhappier. Residents of lower-income neighbourhoods exhibit similar patterns in searches for air quality information but not for health protection, spend less time at home and have more muted sentiment responses.
(For those who consider how your digital data gets used, the data for this paper came from Twitter, Google searches, and a real-time air quality monitor called PurpleAir, along with geographic income data.)
As we also have seen during the pandemic, people with lower incomes have less choices, even if they have access to similar information (emphasis mine):
Why do wealthier locations respond differently to smoke exposure? The measured differences do not appear to reflect differences in exposure information or in overall internet activity, given the consistent response of air-quality-related searches across income groups. Rather, the responses are consistent with lower incomes constraining choice sets and behaviours, including less flexibility in working from home, fewer resources with which to consider purchasing protective technology and (regarding the sentiment results) having other more pressing matters to worry about.
The Seattle Times published an article on October 20th that highlighted “constraining choice sets”. The King County Regional Homelessness Authority opened a “smoke shelter“, though few people used it. Why?
“The long-term effects of breathing in smoke is not going to be like the most highest of priority,” said an outreach worker. This is consistent with the findings from the article: While people living outside may have access to the internet, they likely are not seeking air quality monitors or information about filtration, as they do not have their own windows to close or own spaces to filter.
One of the conclusions of the article about wildfires could very well be applied to the pandemic: a “policy approach of promoting private provision of protection could be biased against disadvantaged groups”. I also suspect that the unhappiness the wealthier respondents reported as a result of wildfire smoke is not dissimilar from the ongoing unhappiness we all are seeing as a result of the pandemic and its social consequences. (It is likely that people who are poor are also experiencing unhappiness; they simply may not have the time, energy, or resources to feel it.)
Maria Yang, MD 