This City Is Killing Me. Jonathan Foiles
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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)10 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.11 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.12 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 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.13 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