INTRODUCTION

      “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 the 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 while 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.