By Jonathan Foiles
From the introduction to “This City is Killing Me: Community Trauma and Toxic Stress in Urban America,” available for pre-order from Belt Publishing.
“Do you think you can keep yourself safe?”
Jacqueline has been in my office for about ten minutes. The tears she’s kept choked back begin to flow down her cheeks. She shakes her head “no” and looks down at the floor. She’s been my patient for a little over a year, and in that time she’s been hospitalized about once a month. This is the first time she’s shown me the depths of her pain; usually her family brings her into the ER after they find a razor blade stashed under her bed or discover her with a rope around her neck.
I begin to fill out the required paperwork while thanking Jacqueline for being honest with me and praising her recovery. She asks if she can call her family. I say yes, of course, and even though I don’t speak Spanish I can guess how the conversation is going. Jacqueline speaks in hushed tones. The voice on the other end sounds frazzled, almost angry. I write down in detail when she told me she wanted to kill herself, how she plans to do it, the number of times she’s tried before. After a few minutes we’re both ready. I put on my coat, and together we walk from the outpatient clinic where I work to the main hospital building across the street.
Jacqueline and I have been meeting weekly, and we’ve developed a good working relationship. It’s hard for me to see her down like this, although I admire her vulnerability. According to Freud I’m supposed to be committed to neutrality and work to contain my own wish to see Jacqueline happy again. I also remember that Freud’s case notes show that he didn’t practice this himself, so I decide to plunge ahead and tell her something that’s been on my mind lately.
“You know, Jacqueline. I do have some news. My wife is pregnant.”
She’s the first patient I’ve told. My wife is now safely outside of the first trimester, so I no longer feel as worried by the possibility of a miscarriage. Jacqueline’s face lights up instantly.
“She is? Oh my God, that’s so wonderful! I know you’re going to be such a great father.”
The smile remains on her face as we walk into the ER, even though I’ve just signed an affidavit swearing that she is at imminent risk of harm. I motion her to one of the vinyl couches in the waiting room while I speak with this charge nurse, and once I am finished we sit next to one another. The television in the corner silently flashes the day’s news. I show her ultrasound pictures on my cell phone, and we wait for her name to be called.
The day on which I hospitalized Jacqueline was in many ways an ordinary day. I work as a therapist at a community mental health clinic on Chicago’s West Side. I started out as a case manager working with adults experiencing homelessness who also had a serious mental illness. Case management gives you a crash course in the inadequacies of our social safety net, but aside from filling out paperwork and making calls I also got to learn about my clients’ lives over cups of bad fast food coffee. I quickly figured out that this is what I enjoyed the most. These experiences led me to become a therapist. The clinic where I work is the outpatient psychiatric department of a safety net hospital on the West Side of Chicago. After Jacqueline was admitted, I went back across the street to the clinic and saw six other patients the same day, all with varying levels of need.
The movement to create clinics like the one where I work began in 1963 when President Kennedy signed the Community Mental Health Act. This act delegated federal funds to build community mental health centers across the country, a notable shift away from the institutional model of years prior. Kennedy’s sister Rosemary underwent a forced lobotomy in 1941 that left her with the intellectual capacity of a two-year-old. I like to think that Kennedy had this in mind when he offered an alternative, humane way to treat those with mental illness.
The actual law was rather toothless and didn’t lead to many notable outcomes, but it played a key symbolic role in the deinstitutionalization movement in the United States. Psychopharmacology had begun to advance beyond what was largely a guessing game into something that resembled a science. Fourteen antipsychotic medications were developed in the United States between 1954 and 1975. The first two antidepressants, iproniazid and imipramine, were introduced in the 1950s. These drugs were far from perfect; the earliest antipsychotics could induce irreversible Parkinsonian-like tremors and cause patients to have a need to be in constant motion (known as akathisia). Iproniazid was later found to cause liver damage and removed from the market. Nevertheless, deinstitutionalization proceeded rapidly, and while the movement should rightly be criticized for sending many patients from a bed and into homelessness, the asylums which went out of business were awful places much prone to abuse that did little to ease the suffering of those confined there.
As persons with serious mental illness were increasingly encouraged to live in their communities, the need for robust out-patient mental health services based in the community increased. Unfortunately, the growth and availability of such services did not proceed nearly as rapidly as the pace of deinstitutionalization, and the gaps in care continue to the present day. For those states with the poorest options for mental health care, providers (social workers like myself, counselors, psychiatrists, psychologists, and psychiatric nurse practitioners) would have to treat six times as many patients as those in well-funded states. Of course this is impossible, so instead people are forced to do without.
In Alabama, for instance, there is one mental health professional per 1,260 residents. Alabama doesn’t even rank last in terms of the percentage of the state budget allocated to mental health services; at 1.5 percent, they’re ranked thirty-fifth in the nation. Arkansas is last with just 0.7 percent. Mental health services are rarely a priority and were particularly hit by cuts made in the wake of the 2008 recession; states slashed at least $4.35 billion from their mental health budgets between 2009 and 2012. The most recent statistics from the Bureau of Health Workforce tracking Health Professional Shortage Areas that lack adequate healthcare estimated that 110 million Americans, roughly a third of the country (but concentrated in urban and rural areas), lack access to a psychiatrist.
In this book I will focus on Chicago because it’s what I know best, but there is no state, no city in America that does an adequate job taking care of its citizens with mental illness. Access to mental health services in Chicago, like so many other things, depends upon your ZIP code. If you live in one of the richest neighborhoods, such as the Gold Coast, there are 4.41 mental health professionals per 1,000 residents. Travel to the Southwest Side where I work and that figure drops to 0.17. But it hasn’t always been like this. In the 1960s and 1970s the city had nineteen community mental health centers spread across the city. Various mayoral administrations chipped away at this until the city was left with twelve. Then came Rahm Emanuel.
Emanuel was sworn in as mayor on May 16, 2011, and within a year he had closed six of the remaining clinics. The stated rationale was to reduce costs as part of a larger effort to trim the budget. The overall savings according to the city’s own figures was estimated to be about $3 million, equaling 0.04 percent of overall expenditures that year. By that point the clinics mostly existed to serve city residents without insurance, and the majority of their patients were Black and Latinx. Emanuel and his staff promised that the 3,000 or so patients of the shuttered clinics would be able to receive services elsewhere, seemingly not accounting for the fact that mental health services in Chicago were already far from adequate. In 2016, the city privatized one of the remaining clinics, leaving Chicago with just five community mental health centers for 2.7 million people.
But Emanuel was not done. Just one year later, he closed fifty schools throughout the city, once again in primarily black and brown neighborhoods. This time, the excuse was to improve outcomes by consolidating services and eliminating poor performing schools with declining attendance. Chicago Public Schools also hoped to save money through the closings, although to date they have not shared statistics on whether or not they were successful. A 2018 study by the University of Chicago Consortium on School Research examined the primary rationale for the closings—academic test scores—and found that students from schools that were closed actually had lower test scores in their new schools, particularly in math. In addition to these quantitative statistics, the students also reported that the process felt rushed to them, left them in mourning for their communities and their schools, and created “us versus them” dynamics in their receiving schools.
Alongside this reduction in access to needed social services and supports, Chicago’s annual murder rate began to spike. In 2012, Emanuel’s first full year in office, the total number of murders in Chicago was 436. The number hovered around 400 until 2016 when the city experienced a massive spike in violence, resulting in 771 murders. The number declined the next year, but only slightly; 650 people were murdered in 2017. Armchair experts of all stripes are quick to suggest reasons for the rapid increase, often in barely-coded racialized language, but no one has been able to identify a single trigger for the rise in violence.
Closing mental health clinics, closing schools, rising rates of violence: each usually gets treated as its own story, but residents of Chicago’s South and West Sides are not allowed that luxury. Chicago’s murder rate did not rise in a vacuum; while it’s impossible to draw causal lines from the mental health clinic or school closings to the homicide rate, it’s hardly a radical thought to suggest that eliminating crucial mental health services while causing patients and schoolchildren to cross gang and community lines in order to see their therapist or simply go to school has not further endangered the lives of the city’s poorest residents. We rarely talk about these issues at all, and conversations that focus upon the actual lives impacted are rarer still. This book aims to spark such a discussion.
Chicago was and is a city that is deeply segregated by race. It is a common stereotype to depict the minority urban dwellers as those who are forgotten by those in power. I no longer find this depiction to be true. Rather, their lives are under constant surveillance from multiple systems and institutions. Thanks to Michelle Alexander’s The New Jim Crow, more people are aware of the evil that is mass incarceration. The fact that 2.3 million Americans, a disproportionate number of whom are Black and Latinx, are currently imprisoned is a national shame. However, there are more than twice that number of citizens who are on parole or probation, creating a system of mass supervision that continues to control their lives long after they have supposedly paid their dues to society.
The intrusion of the state on minority lives is not limited to the police or the criminal justice system, however. We often talk about “the system” or “the government” as being some singular, monolithic entity. This language only heightens its power by making it seem both inevitable and incapable of change. The system, though, has been created by people, and while we can rightly bemoan the influence of big money and corporations in our politics, the systems which we have in place today are still largely the creation of middle-and upper-class whites. Condemning the brutality of the Chicago Police Department is right and good, but if white people continue to use 911 and CPD to police the behavior of people of color we are ensuring that nothing will change.
Most are not willfully blind but rather ignorant of such things. If you live in a world where the rules are largely created by people who look like you for your benefit, it’s hard to see the invisible lines setting you aside from everyone else. Many residents of Chicago will never have a negative interaction with Chicago Public Schools or interact with the Department of Child and Family Services at all (unless it’s to become a foster parent), so it can be hard to know just how broken those systems are for people of color. Decades of right wing attacks against “big government” have lent a sad aura of inevitability to the failure of such bureaucracies. Perhaps they are working exactly as intended.
When one considers the history of minorities in America since its founding, one can clearly see a system that has adapted with the changing tides but always had as its goal the elevation of whites at the expense of minorities. There is nothing inevitable about this; it’s the result of a number of policy decisions and ever-mutating forms of racial panic. Oppression takes many guises and sows the roots of trauma throughout generations.
You may be wondering how these broad historical trends relate to mental health on an individual basis. Our lives and our experiences shape the way we perceive the world and impact our vulnerability to depression, anxiety, and the like. We’ve made great strides in the ways that we’ve normalized experiences of mental illness, but at times these conversations obfuscate the different nature of mental disorders. If you begin vomiting one evening, you will most likely consider a number of different scenarios. Maybe you ate at a new restaurant and thought that the fish had a funny smell. Maybe the person whose desk is next to yours went home sick with the stomach flu. Eventually, though, either on your own volition or with the help of your doctor, you’ll most likely be able to identify a cause rather quickly and treat the illness appropriately with rest or medication.
Diagnosing mental illness does not work like this. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the book all mental health professionals use to assign a diagnosis. To merit a diagnosis of major depressive disorder, for example, you must have had at least five of the following symptoms for the preceding two weeks: persistent depressed mood, lack of pleasure in almost all activities, fluctuations in appetite, sleep disturbances, lack of energy, feelings of worthlessness, difficulty concentrating, and recurring thoughts of death. There is no one way to end up with these symptoms, though. As near as we can tell, some people are born with a genetic disposition to melancholia that can be exacerbated by life events, and others probably would not have developed clinical depression if they hadn’t lost their job or gone through some other painful development. Treatment will probably not look uniform either; both psychotropic medications and therapy are effective, but depression has many permutations and what helps one person could fail to help the next.
We diagnose people, not cultures or neighborhoods, with depression. This singular focus can help obscure the environmental factors that contribute to mental illness and minimize the contributions our society makes to the mental suffering of the poor. It is far easier to feel depressed if you live in a neighborhood that has experienced chronic disinvestment, has few supportive community resources available, and is marred by gun violence.
This also makes it much more difficult to treat. How does one heal a whole neighborhood? I can do my best work as a therapist to help someone improve, but there is only so much that can be accomplished in individual therapy before we run up against the structures that continue to perpetuate such suffering. We need to cast a bigger vision.
In public health, these outside factors that impact the functioning of individuals within their communities are known as “social determinants of health.” According to the Centers for Disease Control and Prevention, such factors include unstable housing, low income, unsafe neighborhoods, and poor education. I will be utilizing this framework throughout the book to analyze how policy decisions and priorities have negatively influenced the mental health of my patients, but I want to take this conversation a step further.
Consider employment as an example. It’s fairly obvious from the data that being unemployed or underemployed can be deleterious to one’s physical and mental health. One solution that is often proposed is workplace development programs. These can indeed help, but what if there simply aren’t jobs located within the community because of systematic disinvestment? What if the jobs which are available are mostly within the retail and service sectors and don’t pay a living wage? What if the employers refuse to hire someone who has been incarcerated? What if the jobs don’t allow flexible scheduling so parents can be present for their children? And how did these communities get stuck with such poor employment options in the first place? We need a framework that recognizes these systemic issues and how they disproportionately affect people and communities of color.
We have a framework in mental health for understanding the ways in which a traumatic event can impact an individual: posttraumatic stress disorder. We haven’t done nearly as good of a job at accounting for the other mechanisms by which outside events impact a person and a community’s wellbeing. In this book I will talk some about individual traumas, but my focus will be upon on the larger traumas that occur within a community (unemployment, poverty, lack of affordable housing, violence) and within history (Jim Crow laws, mass incarceration, forced displacement, redlining).
These traumas exert a different sort of pressure upon the individual, creating what’s known as toxic stress. Consider this example: Two young boys are bullied at school. The first boy, “Michael,” goes home with his grandmother who talks to him about it, makes him a snack, and helps him forget about it for the evening. She also resolves to address it the next day with his teacher so it doesn’t become a larger issue. Michael went home in an emotionally aroused state, but due to attentive caregiving he is calm by the time he goes to sleep and isn’t bothered by the time he goes to school the next morning.
“Thomas” is also bullied, but his experience is different. His caregivers have to work irregular hours to make ends meet, so when he goes home a neighbor is nearby to keep an eye on him but Thomas doesn’t have anyone to talk to right away. His emotional arousal level stays high. His parents finally arrive at home, and right after dinner his father starts drinking. His stress level increases. He goes to his room because he knows what comes next. He can hear his father slapping his mother around and calling her names. He is unable to talk to anyone about being bullied, and he is more stressed when he goes to sleep than he was when he came home. He goes to school in the morning more anxious than when he left, is bullied again, and his stress skyrockets.
If these conditions continue for Thomas, he will be at great risk for both physical and mental health issues down the line. He will have a greater chance of being unemployed or underemployed, have more relational instability, express less satisfaction with his overall life, and will most likely die sooner. Now imagine communities that, because of constantly cascading waves of trauma upon every level, are made up almost entirely of Thomases. These are the conditions we have created in urban areas throughout the country.
Most therapists who work in community health look like me and not like the clients we serve. The profession is aware of this; almost every workplace as well as every licensing and accrediting body require some sort of annual training in cultural competence or, better, cultural humility. The skein of white privilege never fully reveals itself in a three-hour seminar; working at this job requires you to pay constant attention to the way in which your privileges have structured your world. My own profession, social work, has social justice as one of its core values, according to the National Association of Social Work. Still, though, the way in which we approach mental health work is often divorced from this lofty goal, if not in theory than in practice. In my own graduate program of social work, I reached a point where I had to choose between a clinical (that is, mental health-focused) or social administration (primarily policy-based) approach. The longer I work at my job, the harder it is to tell the two apart. This book is my attempt to bring both sides together.
In the pages to come, I will introduce five of my patients and demonstrate how their lives have been impacted by policies and practices outside their control. We will revisit Jacqueline, a transgender woman of color trying to survive and complete her journey to become herself. You’ll also meet Frida, a deeply traumatized child who grew into a traumatized parent whose children were removed from her care by the Department of Children and Family Services; Robert, who endured trauma in the Cabrini-Green projects and refashioned a self-narrative that made him an African prince in exile; David, who failed out of a selective enrollment high school and lived amongst rats and the books he couldn’t stop hoarding; and Anthony, who lost his son to a random act of gun violence and was still trying to pick up the pieces of his life years later.
I do not want you to feel sorry for my clients. I don’t feel sorry for them, and I don’t think they would want anyone else’s sympathy either. Sympathy does nothing to change their situation in life. Rather, I want you to see them, to be forced to confront the impact that policy decisions have upon the lives of our cities’ poorest residents. Their stories give me hope, yes, but even more than that they challenge me. They challenge the advantages conferred to me because of my white skin, who my parents were, where I grew up, and who I love. I chose none of those facets of my identity, and neither did they.
As is standard practice within my field, all names and identifying details have been changed. I have preserved enough of my patient’s stories to illuminate my thesis but have left out or modified those details that are not relevant. Out of respect for their lives and experiences, the rest has been told exactly as it occurred.
I’m aware that by sharing these stories I risk fashioning myself into the “white savior,” an outsider who comes parachuting into urban communities of color to save them from their woes. That is not my intention in writing this book, but I realize the tension inherent in the project. I will do my best within these pages to let their stories speak for themselves. I may have captured their attention for an hour every week or two as we worked together, but real lasting change can never occur in my office alone. Any progress my patients have made is due to their dedication and hard work; I am privileged to help guide them along the way and be their cheerleader. I strive to always listen to my patients without interjecting my own construct of what I think is going on, and what you will see in this book is largely a reflection of what I have learned by listening to them. ■
Jonathan Foiles is a writer and mental health professional based in Chicago. He writes a blog for Psychology Today and has previously written for Belt and Slate. He can be reached at [email protected].
Cover photo by William Rickman.
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