This City Is Killing Me
Read a selection from my forthcoming book on community trauma and toxic stress.
Posted Jul 30, 2019
"Do you think you can keep yourself safe?"
Jacqueline has been in my office for about 10 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. 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.
As people 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.
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 who closed six more of them.