“Give ‘em out like candy,” advised a senior resident while handing me a stack of small flyers. The text outlined a list of services provided by a nearby community resource center for help with things like housing, food, education, employment, and legal issues. I never thought this quarter page of paper would prove so critical throughout my time working as a psychiatry resident in our county clinic. I also did not expect my job to share so much with the modern work of cops, highlighted in recent weeks following the police killing of George Floyd. In fact, both us in psychiatry and those in policing are often tasked with managing the failures of American social policies – and neither of us is very good at it. Unaddressed basic needs – like those spelled out on the prized flyer – are frequently a significant driver of my patients’ symptoms. I feel helpless when the most I can do is offer the piece of paper. And not uncommonly, my patients have returned to the next visit reporting they went to the resource center only to be placed on a months-long waiting list for the relevant assistance. My most vulnerable patients and I are forced to do our best from where we are and with what we have. However, an antidepressant for your homelessness and cognitive behavioral therapy to “reframe” your food insecurity clearly leaves something (everything) to be desired. When these sorts of interventions unsurprisingly fail to work, patients are left in the same position or worse, potentially experiencing side effects and definitely the pain of our persistent neglect of their fundamental needs. At the same time, taxpayers, in the case of Medicaid, cover the bill for a psychiatrist instead of a social worker or better yet preventive policies. This phenomenon is referred to as “the medicalization of poverty.” People present to the healthcare system with ultimately social problems and, without great alternatives, we as providers react, assigning a diagnosis or offering a medication (“something”) despite the true cause of their suffering or clear benefit. A number of tragic outcomes, such as aspects of the opioid epidemic, are a consequence of this dynamic. Stanford’s Dr. Anna Lembke has described instances of opioids acting as “a proxy for a social safety net,” prescribed at times as a quick fix, conscious or not when clinicians are confronted with profound and immediately unfixable social problems. Not dissimilarly, much of modern policing arguably functions as “a proxy for a social safety net.” The most downstream point in a chain of missed opportunities, police are currently asked to step up as makeshift social workers, mental health professionals, trauma experts, and more. In the now widely circulated words of former Dallas police chief David Brown, “We’re asking cops to do too much in this country. … Every societal failure, we put it off on the cops to solve. Not enough mental health funding; let the cops handle it … Here in Dallas, we got a loose dog problem; let’s have the cops chase loose dogs. Schools fail; let’s give it to the cops … That’s too much to ask. Policing was never meant to solve all those problems.” Take this headline from last year: “Police Train to Be Social Workers of Last Resort.” In the article, several well-intended police officers express support for a newly mandated mental health and de-escalation training to better prepare them for calls related to mental health issues. But if we allow ourselves to zoom out for a moment, it becomes obvious we are far down a misguided path. If you had a problem with your car, but there wasn’t a mechanic available, you wouldn’t spend your time and money training your plumber to fix your car. It’s nice that your plumber’s willing, but it shouldn’t and doesn’t need to be their job. It’s time to end both our medicalization and criminalization of social problems and free up resources for the people and programs that we know are best equipped to address the relevant root causes. With a key root cause being systemic racism, the solution will require systemic re-thinking. This sort of reimagining of and reinvestment in our social policies would help us avoid inappropriate, expensive, and potentially dangerous “band-aid” solutions. Let’s make a world where police and psychiatrists don’t have all that much in common. Sara K. Zachman is a psychiatry resident. Source
