Category: Systems

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Education Medicine Policy Public health psychiatry Systems

What is Mental Health? (02)

To continue from my last post about “what is mental health?” and “what am I doing?”, let’s look at another figure from the paper What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey:

Figure 2C

This model argues that an individual’s mental health isn’t the sole product of that single person (because, yes, things are complex). “Society” also contributes to and affects a person’s mental health.1

The Covid pandemic provided plenty of empirical evidence that “society” has enormous influence on the mental health of individuals. Over a third of young people reported “poor mental health” and nearly half reported they “persistently felt sad or hopeless” in 2021. There were nearly 30,000 (!) more deaths related to alcohol when comparing 2019 to 2021. Two out of every five adults reported “high levels of psychological distress” at some point during the pandemic.2

The pandemic isn’t the only example of the power of “society” on mental health. Survivors of mass shootings can develop psychiatric symptoms or disorders. Residents of Flint, Michigan, could only access drinking water contaminated with bacteria, disinfectants, and lead. This contributed to elevated rates of psychological conditions like depression and PTSD. Poverty increases the likelihood of depression and anxiety.

“Imagine how many people I wouldn’t need to see if people never experienced homelessness!” I mutter (or exclaim) at least once a month. It’s not just homelessness: It’s working three jobs to make rent; it’s trying to keep the family fed and housed when one parent has major medical problems; it’s trying to leave an abusive partner; it’s trying to keep things together when a family member has an alcohol or gambling problem. Because much of my career has been in the “deep end” of the system, I often witness how misaligned and rigid institutions often bruise and scar the psyches of individuals and populations of people.

Maybe context matters more in psychiatry than in other fields of medicine. When I think, “What am I doing?”, I often wonder if I should work “upstream” in prevention and early intervention to help change these contexts. This includes advocacy for action that is outside the purview of medicine, such as lowering barriers to housing or increasing regulation of firearms.

Some physicians (and others) have argued that doctors should “stay in our lane”, that we should focus on treating conditions that we are trained to treat. Medical school didn’t teach me how to prevent psychotic disorders; it trained me to identify and treat schizophrenia. In residency I didn’t learn how to develop policy and programming to prevent war and rape; I was trained to provide care and support to someone with PTSD. I can help someone choose to put their gun away so they don’t shoot themselves; I don’t know how to organize people to persuade elected officials to change gun regulations.3

Of course, there’s a middle ground. My clinical experience and expertise give me the anecdotes and data to advocate for system changes. These system changes can improve the health of individual people. Furthermore, there are real people who have real psychiatric problems who need real help right now. As Paul Farmer said,

To give priority to prevention is to sentence them to death—almost to urge them to get out of the way so that the serious business of prevention can start.

I once worked for a medical director who often said, “I’d love to work myself out of a job.” It sounds disingenuous, but it’s true: I completely agree. How wonderful would it be if fewer people experienced psychological distress and problems with living! (Given the ongoing shortage of psychiatrists and other mental health professionals, this would be a win for literally everybody.) What if people didn’t believe that suicide was the best option? Or if people didn’t have to grapple with unending worry about where they will sleep tonight or when their next meal would be? I wholeheartedly concede that crafting legislative language and designing policies and programs are not my strengths. However, it also makes little sense to me to keep my head down and simply treat illnesses and suffering that can be prevented. Things don’t have to be this way.

(1) Again, if we’re going to be picky about words, I prefer the word “context” over “society”. “Society” suggests something uniform, when there exist microcultures within one society. For example, I’ve worked as a homeless outreach psychiatrist in New York City and Seattle. In New York I wore bright blouses with large ascots. In Seattle I wear dark hoodies. Same job, same society, different contexts.

(2) We can argue about whether these reports of distress and their associated behaviors reflect “mental illness” versus “mental unwellness”, in reference to part one of this series.

(3) While media reporting often focuses on guns and homicide, firearms cause more suicides than homicides.

Categories
Blogosphere Medicine Systems

Brain Snacks.

It’s a short post this week, though the links will take you to nutritious brain snacks (or hors d’oeuvres, if you identify as classy):

24 Hours in an Invisible Pandemic. This is an excellent example of data visualization about the experience of loneliness in the US.

26.2 to Life. This documentary is about the San Quentin Marathon. The athletes are inmates at the San Quentin prison. The course is 105 laps around the prison yard. (The virtual premiere is this weekend.)

30 Days of Healthcare. Dr. Glaucomflecken’s series of short videos about the US health care system is accurate, devastating, and, when it can be, amusing.

We Are Not Just Polarized. We Are Traumatized. This long essay is provocative, thoughtful, and worth the time to read. (Side commentary: The term “trauma response” is a relatively new phrase and, as far as I know, isn’t rooted in robust psychological or biological principles. I worry that the usage of “trauma response” may also dilute the experiences of people who meet formal criteria for the diagnosis of PTSD.)

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Medicine Observations Systems

On Who People Think You Are.

The author wearing a black face mask while holding a soft serve cone. The wall behind her features a cone that looks like a fish that has green soft serve in it.
A photo of yours truly wearing a mask. Photo credit to Amy L.

There were two patients in the hospital room. Both were elderly East Asian males, each reclining in his bed. The curtain that divided the room in half was pulled forward, offering the illusion of privacy. Sound still travels through cloth.

Outside the hospital room I rubbed sanitizer onto my hands. The only size of blue plastic gowns offered was extra-large. My arms swam through the enormous sleeves as I pulled the gown over my yellow sweatshirt. The only gloves available were size large, which I slid onto my hands before putting goggles on my face. I was already wearing an N95 mask. Only my black track pants and black sneakers emerged from my blue contact precautions.

My dad had alerted me that, overnight, he was moved from a private isolation room into a shared room. His roommate, though ethnically Chinese, spent much of his life in a different country in Asia. He spoke limited English. They quickly discerned that they both speak Chinese.

Within a few minutes, I pushed the curtain back so the divided room became whole. Chinese conversation flowed among the three of us, punctuated by occasional wet coughs rattling through the torsos of the two men.

If I looked right, I could see through the window in the door. Sometimes staff walked by, paused, and waved. One was a man in his fifties who, at one point, opened the door and said to me, “We’re thinking we might discharge him today.” He gave me a thumbs up sign and shut the door before I could respond. He wasn’t my father’s doctor.

Later, my father’s nurse walked in and asked who I was. “Oh,” she commented, “I thought you were the interpreter.”

The other man’s nurse walked in minutes after that and asked who I was. “Oh,” she said, “I thought you were a physical therapist.”

Later, in the hallway, the man who appeared to be in his fifties waved me down. He was wearing a long white coat and there was a red label on his ID badge that said “Doctor”. His eyes smiled at me as he asked, “How is your dad doing?”

I paused before asking, “May I ask who you think my dad is?”

“Mr. Other Guy,” he said effortlessly.

“That’s not my dad.”

“Oh?”

“The other Asian man is my dad.”

“Oh.” He was anchored in awkwardness.

“Thanks for taking care of Mr. Other Guy,” I said before walking away, releasing the anchor. He waited a beat before veering off in the other direction.

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Consult-Liaison Observations Systems

Demoralization and Status.

This TikTok video provides an accurate (and shouty) summary of the National Guard member who leaked classified military documents. In short, it appears that the Airman shared these documents in an effort to elevate his status within an online cohort. (Someone on the internet opined something like, “This was a cosmic level of stepping on a rake that hits you in the face.” Correct.)

We all have engaged in behaviors to heighten our position in relation to others. Depending on who you ask, some argue that we are constantly adjusting our behaviors to communicate and maximize our status.

Our perception of our own status is not always accurate. It seems that we sometimes exert tremendous effort to demonstrate high status to make ourselves feel better, rather than to assert that we have higher rank than others. (Much research has been done to show how humans assess and react to status.)

Maybe it’s a stretch to link demoralization and status to each other, though this is what has come to my mind over the past few weeks. Demoralization is usually framed as an individual process, whereas status involves groups of people.

Merriam-Webster provides the following definitions:

  • demoralization: weakened morale; to be discouraged or dispirited
  • status: position or rank in relation to others

I’ve written about demoralization before, though it was more in reference to individuals experiencing medical illness. The paper I reference in that post offers this definition of demoralization:

the “various degrees of helplessness, hopelessness, confusion, and subjective incompetence” that people feel when sensing that they are failing their own or others’ expectations for coping with life’s adversities. Rather than coping, they struggle to survive.

This is where I might be speaking out of turn: Is it fair to apply principles usually applied to a single person, particularly one’s intrapsychic processes, to groups of people? (Would I be a true psychiatrist if I didn’t use the word “intrapsychic“?)

But let’s consider this together. I’m starting with the Airman, but that isn’t actually the point of this post.

What if that Airman was feeling demoralized? Within his Discord group, he may have been able to rely on his age to maintain high status. What teenager doesn’t think a 21 year-old person is cool? But what if group dynamics shifted and, suddenly, the Airman was no longer the proverbial “alpha”, but had been demoted to a “beta”?

In an effort to restore his status, he might have employed any one of the strategies to reduce his vulnerability:

The sharing of classified military documents isn’t a demonstration of resilience, but it is a display of power that produces postures of coherence, agency, and courage. In sharing classified papers that only he has access to, he is dissolving any confusion he or anyone else may have about his “rightful” status. To combat feelings of helplessness, he demonstrated agency to provide evidence of his power. It takes some flavor of courage (…) to share sensitive information. By sharing these documents with his Discord cohort, he facilitated communion, established a purpose for himself, and got to bask in the gratitude of his friends. What a way to escape the isolation that accompanies a degradation of status!

So let’s consider other things that are happening in the nation that might be reactions to demoralization and efforts to reinstate high status: states banning TikTok, banning abortions at six weeks, protecting access to transgender care.

Again, is it fair to apply individual, intrapsychic processes to groups of people, particularly groups of people in politics? (But aren’t political groups comprised of individual people?)

The passage of laws—something that feels real and concrete—brings coherence and fosters communion! It brings hope and purpose! Doing something—exhibiting agency—summons courage and generates gratitude! Your rank in relation to others feels like it is rising. Even though there are people who will view your actions as further erosion of your status, it doesn’t matter: You feel better. You feel more power.

The passage of laws reduces confusion, despair, and helplessness. Instead of feeling isolated, people can channel their feelings of helplessness and resentment into doing something, which makes cowardice evaporate. You may already possess high status—all the other people around you may already defer to you because they view themselves as having lower status. And, yet, if you feel demoralized, the positive regard from others may be insufficient to elevate your own status in your own eyes.

We can never get away from ourselves.

Categories
Funding Policy Public health psychiatry Seattle Systems

Crisis Care Centers Aren’t Enough.

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.