Category: Systems

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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. 

Categories
Education Homelessness Policy Public health psychiatry Systems

What I Talked About: Complexities.

Many thanks to those of you who left comments or sent me a note in response to my call for suggestions for a presentation about homelessness and mental illness.

I gave the presentation earlier this week and ended up presenting (a) homelessness data specific to Seattle-King County, (b) general data in in published research about rates of different psychiatric conditions in people experiencing homelessness (there’s actually not a lot of data about this; my understanding is that there is a national study underway right now to assess people experiencing homelessness through structured psychiatric interviews), and (c) the topic of “Involuntarily Removing Mentally Ill People from Streets“. I asked the group—students within various health professions schools—for their thoughts about New York City’s plan.

Many of the students were unfamiliar with involuntary detention for psychiatric reasons, along with the process for how that happens (the laws in Washington State differ from those in most other states in the nation; namely, physicians and other mental health professionals in Washington State cannot detain people directly; we must call a third party, called Designated Crisis Responders, and refer someone for detention). The initial group consensus favored civil liberties; they spoke of loss of dignity, the psychological and physical trauma that can result from involuntary detention, and the importance of autonomy.

When the scenario was adjusted so that the person who was experiencing homelessness and major psychiatric symptoms was someone that the students knew and loved, they quickly changed their arguments to support involuntary detention. When we love someone, we are more comfortable taking away their rights.

Like many complex issues, “right” answers escape us as more facets of the problem are illuminated. Involuntary detention itself is a complicated issue and, because most people are not experiencing homelessness, the majority of people who are detained are people who have an indoor place they call home.

Some research indicates that around 76% of people experiencing homelessness also have a psychiatric disorder, though the association is complex and likely goes in both directions: Some people have a psychiatric condition that contributes to poverty and then homelessness (e.g., losing a job); others become homeless and then develop a psychiatric condition due to the challenges of not knowing where you will sleep at night.

I continue to learn the complexities of working at the intersections of poverty and mental health. I am grateful that more people are interested in this work, too. I hope that things don’t have to get worse before we can offer better help and care to these individuals, who are ultimately our neighbors.

Categories
Medicine Policy Public health psychiatry Systems

Reflections on Some Health Care Systems.

Items related to systems of health care that I learned and thought about this week:

National Medical Association. I am embarrassed to confess that, nearly 20 years after graduating from medical school, I learned only this week about the National Medical Association. This came about while I was learning some of the history of the American Medical Association (AMA). In short, the National Medical Association was created because the AMA would not admit Black physicians into the organization. (I have never been a member of the AMA. My reasons have been squishy; I never truly believed that the AMA represented me or my interests. That hasn’t stopped the AMA from sending me invitations in the mail to join! It seems that over 80% of physicians are not AMA members, so I’m certainly not alone.)

Alexander Graham Bell and Eugenics. This Journal of the American Medical Association (emphasis mine) editorial from 1908 reports:

The subject of the production of better men and women was brought before the American Breeders’ Association by Professor Alexander Graham Bell, the inventor of the telephone, who for many years has been interested in certain social questions, especially those relating to the condition of the deaf and the result on the next generation of the consanguinity of parents as regards the production of deaf and blind children.

No one ever brought this up when we learned that he invented the telephone.

It appears that Bell’s interest in “breeding” was his observation, though the collection of some statistics, that parents who are related to each other seem more likely to bear children who are deaf. Bell made “an appeal for the collection of statistics by trained men who are interested and who have the opportunity to secure the definite detailed information” related to “the production of better children”. The unnamed author(s) of the editorial go on:

We are securing survivals to a much greater degree than before, and now it becomes a duty to secure, so far as it is possible, the origin of members of the race who will be worthy of survival. After all, the most important problem in evolution is not so much the survival of the fittest as the origin of the fittest.

Over 100 years have passed and this ugly question of “breeding” persists.

The Chinese Exclusion Act. I’ve commented on this Act before (here and here), but here’s an opportunity to pile on the AMA even more. In 1901, the Journal of the American Medical Association published a “minor comment” about “The Exclusion of the Chinese“, which you can view in its entirety in the link above.

Reading this made me think of vile rhetoric that has revived during this Covid-19 pandemic. Recall recent references to “disregard of sanitation” due to “[maintainence] to the fullest extent their oriental habits and traditions”. The Chinese, they just won’t do as we do.

“That this is a Christian country and we regard them as heathen, should not make us altruistic to our harm.”

Do we hear echoes from 1901 in the US’s current Covid test requirement for travelers from China?

Prescriptive Authority for Psychologists. There is a House bill in the Washington State Legislature that will give prescriptive authority to psychologists. Five US states currently allow psychologists to prescribe medications.

While it is easy to stumble into a debate about whether this should happen or not, I think this is a distraction. This debate is a manifestation of failure in public health policy.

Instead of trying to increase the number of people who can perform a highly specialized task, why not increase the availability of community supports and services so people don’t need highly specialized treatment?

Consider the decrease in anxiety and depression that would result if people were confident they could pay their rent? feed their families? take time off to care for their newborn? secure an education or training–whether college or vocational school–that supports stable employment?

Think of the decrease in stress and trauma if people had better options than to sell drugs or sex? if neighborhoods had more green spaces and less air and noise pollution? if they had adequate and essential protections as “essential” workers?

Medical Mistrust and Meeting People Where They Are At. This paper about medical mistrust, racism, and health prevention describes an elegant way to recruit study participants: “collection of data [occurred] primarily in barbershops, venues with documented recent success in reducing blood pressure in African-American men”. It is elegant because it is simple, effective, and successful.

When I read this, I recalled a suggestion my father had around the time the Covid-19 vaccines were released. He lives near several Asian grocers, many of which are more like bodegas than grocery stores.

“Why don’t they set up vaccination stations outside these grocery stores? Everyone needs to eat. Elderly people go to these stores all the time. Laborers get snacks and cigarettes. Make it easy for people.”

Sometimes (often?) the best and most effective health care happens outside of medical spaces.

Categories
Consult-Liaison Homelessness Public health psychiatry Systems

On “Involuntarily Removing Mentally Ill People from Streets”.

Photo by Mart Production

There’s been buzz about the report of New York City to Involuntarily Remove Mentally Ill People From Streets. The comments section of the article as well as letters to the editor articulate the complexities around this issue. I also appreciate that the New York Times solicited perspectives from people experiencing homelessness themselves.

In trying to think through this myself, I turn to two mental models: First, what problem are “we” trying to solve? Second, can health care ethics provide guidance here?

What problem are “we” trying to solve? This requires reading the mind of New York City Mayor Eric Adams, which I cannot do. He has argued that The Royal We have a “moral obligation” to solve the problem of “assist[ing] those who are suffering from mental illness”. If we take him at his word, then we can fold his argument within the framework of medical ethics.

If, however, Mayor Adams is trying to solve a different problem (e.g., make homelessness invisible; reduce the number of complaints from the public about people exhibiting unusual or dangerous behaviors; demonstrate that he is “doing something” about homelessness, etc.), then the framework of medical ethics may not apply. If he is trying to solve a different problem, then instead of assisting those who suffer from mental illness, he is using those who suffer from mental illness to assist him and his actual agenda.

Of course, he may be trying to solve multiple problems through the guise of only one.

Can health care (or medical) ethics provide guidance here? One model used in medical ethics is called the four box model. Of note, the four boxes focuses on individual patients, not on populations of people.


Medical Indications
(Beneficence and Nonmaleficence)
Patient Preferences
(Respect for Autonomy)

Quality of Life
(Beneficence, Nonmaleficence,
and Respect for Autonomy)

Contextual Features
(Justice and Fairness)

Medical indications asks what benefits and harms the patient might experience from interventions. Would involuntary psychiatric hospitalization help people with mental illness who are homeless? Some of them, yes. Would it help all of them? Maybe, maybe not. Could involuntary psychiatric hospitalization cause harm? That is not the intention, but sometimes it does. For reasons valid and invalid, it might discourage people from engaging in psychiatric services ever again. Anything involuntary always involves some degree of coercion, which people generally dislike.

Just because people are behaving in unusual ways and are living outside does not mean that psychiatric hospitalization is guaranteed to “fix” them. I do not mean to diminish the care people receive in psychiatric hospitals. People often need more than involuntary psychiatric hospitalization to get and stay well. Sometimes there is no medical indication for psychiatric hospitalization (involuntary or otherwise) for people with mental illness who are experiencing homelessness. Sometimes they just need a stable place to live.

Patient preferences refers to the dignity and choices people should have in living their lives. Some people would rather take pills by mouth every day than receive a monthly injection of medicine. Some people would prefer not to take any medicine at all. Patient preferences matter.

Some people who are living outside and behaving in unusual ways may not want to be in a hospital. Or maybe they are willing to be in a hospital, but not at that moment—maybe they have other things to take care of that day. Or maybe they are only willing to go to certain hospitals on their own, not at the behest of law enforcement. By definition, involuntary removal of people from the streets disregards patient preferences. Options other than psychiatric hospitalization, such as crisis centers, partial hospital programs, or day programs, can help preserve patient preferences and hence their dignity.

Quality of life describes the patient’s quality of life. Interventions should provide benefit, minimize harm, and maximize the dignity and choices of patients. This does not refer to the quality of life of the general public. If involuntary removal and psychiatric hospitalization are the means to the end of improved quality of life, how can these improvements be sustained following hospitalization?

It is absolutely true that psychiatric hospitalization can be life-saving and life-improving. However, people need and benefit from ongoing care and services following hospitalization. Mayor Adams’s target population also need places to live to maintain their gains. If you’ve ever been hospitalized for any reason, can you imagine the course of your recovery if you had no place to go upon leaving the hospital? How are you supposed to rest when you don’t know where you will sleep that night? Quality of life requires planning and sustained care; acute interventions alone rarely produce improvements in quality of life.

Contextual features are the intersections of a patient’s care with the rest of the world. There are a multitude of contextual features in Mayor Adams’s plan (and it makes me wonder if the mayor consulted with any partners prior to making his announcement). Here are a smattering of contextual features that come to my mind:

  • How will first responders decide if someone has a mental illness? What if they think someone has an “attitude problem” and instead refers them to jail? How severe do psychiatric symptoms have to be? Will only those who attract the attention of law enforcement be involuntarily removed? (What about the elderly woman who keeps to herself and has been homeless for decades and won’t move indoors because the voices tell her that she will die if she does?)
  • How will hospital psychiatrists react to people who, in their professional opinion, do not need hospital-level care, though the law argues otherwise? Will psychiatrists become agents of social control on behalf of the jurisdiction? There are some parallels here to the overturning of Roe v. Wade: Some gynecologists are not performing abortions, even though there are medical indications to do so, because of the law. Here, psychiatrists may proceed with involuntary treatment even though there are no medical indications to do so… because of the law.
  • Let’s say someone experiencing homelessness is involuntarily removed from the street and is psychiatrically hospitalized. Where will they go upon discharge? What if they prefer returning to the street instead of a shelter? What if they have no sources of income and there is insufficient affordable housing? (This is not actually a “what if” question.)
  • What about all the people who are homeless, but do not demonstrate symptoms of mental illness? Are there any opportunities to prevent or reduce the chances of mental illness in this population? (Yes, by increasing access to stable housing.)
  • What about all the people with severe mental illness who are not homeless? Are there any opportunities to prevent or reduce the chances of homelessness in this population? (Yes, by increasing access to and flexibility of psychiatric services.)

The four box model here highlights some ethical problems with Mayor Adams’s plan, though there are solutions to increase beneficence, autonomy, and justice while reducing non-maleficence. My hope is that Mayor Adams and leaders of other jurisdictions with similar ideas will take heed.