The Mental Health Crisis in America

Before the Pandemic America was gripped with a mental health crisis. Addiction, suicide, violent crimes were on the rise. Mental health was hard to access and almost inexistent in some places. Depression and anxiety were the most reported issues, with poor resources and over burdened and poorly paid mental health workers expected to be magicians with no wand and no trust. 

The situation became alarming as the Pandemic wore on and we are now at a crossroads of addiction, severe mental health and isolation that is leading to urban decay, chaos and fear. There are no resources still, the moneys always promised fall in the pockets of ex-politicians, their buddies and relatives and by the time any resources trickle down to those in need, it is neither sufficient nor effective. Yet the facile ways in which leaders and those politicians (some dare call themselves “activists”) speak of the "need for more mental health" makes it seem as if they have the will and the way, but a shadowy figure is stopping them from showering communities with those much needed resources. It's a farce, a joke and it gives mental health workers a reputation of not working hard or well enough. We are in general, poorly paid, overworked and well-meaning professionals, being pushed around by corrupt institutions who pocket the grants and provide little above minimum wage for highly qualified and often dangerous work. The lack of oversight, the cronyism, the outright corruption seen in many community non profits needs to be addressed, before any change ever takes place. Of course corruption is an equal opportunity vice. The well connected and well spoken, the snake oil peddlers get wealthier and everyone else becomes more desperate. 

No, there will not be any change coming to this country in the mental health landscape. There will be a few more thousand people who will be wealthier, have better homes and bigger cars, who can eat in fine restaurants, and get well trained but unconnected chumps to write their proposals and account or not, for their expenses. 

After all, there are some philanthropists out there who are handing out the billions they got through divorces or deaths, and who think that just handing out money is sufficient. No accountability, just graft. And the poor and the addicted and the mentally ill never reap the benefit of their "generosity". 

the mistakes of a rookie

 I started my own practice as a psychotherapist after dreaming of it for years. COVID19 changed my plans and after saving enough to keep me through a dry spell, ensuring that  I would not have to stay in NYC and not renew my lease, and all matters of other small details, I handed in my resignation. Due to vaccines and the need for me to work another month, I stretched my work yet another month and then, my nice insurance, my colleagues, and superb ones they still are, the support team that ensured that all I had to do was show up, my great office, all of that, puff! gone!
I was/am on my own, now for more or less 9 months, the time it takes to gestate a baby. It was slow going, a few hits and misses, and slowly I started to accumulate clients. My agenda was filling up, sometimes more, sometimes less. 

I confess to having little business acumen, to being too insecure and too fearful. I realized soon, that every person I spoke to, I would have to be doing an interview AND presenting my resume. Supposedly under 15 minutes. Ahahah! Many people I am sure got what they needed from my 45 minute session and decided, hey, she provided me with the tools I need to get going. Those were the ones that maybe did not need therapy after all. Not everyone does! People can have a supportive family, circle of friends and community and feel open enough about their issues that the need for therapy is covered. 

So on to the other blunders...

Giving clients 70+ minutes when their insurance is practically threatening anyone who puts down the code for 53 minutes that we will get audited. Good enough. But time management is also good practice. 

These were the easy ones. The hard ones have been, being ok with last minute cancelling, like, sorry I know you sent me a Zoom link but I have a....and my reply always being, "ok life!"

I don't think I'll ever charge anyone for not cancelling within 24 hours but having regular notice is a must that I have to communicate initially. It was so bad that in the last 2 weeks of December, my first and last 2 weeks of working in the last 2 weeks of December, I scheduled and rescheduled and descheduled most of my clients. That's not acceptable, not when people know that they will be having vacations. This might have been partially my fault! I might have shown anxiety and reluctance. I'll never know. My agenda, I need to use a paper agenda, was so crisscrossed that as the new yaer started I totally forgot a fairly new, but really reliable client and that is, to me unacceptable. 

New rules:

Scheduling on Zoom at the beginning of the week. Be parcimonious with people who are always trying to change the agenda, be compassionate with the ones who are always there. 

The age gap is real. I got a slew of youngsters from fancy universities and proceeded to lose them because, I could not understand their issues, I don't think most of them needed therapy, more than a few times at least, and my training was different. This issue will be covered in a new blog issue that no one will read. 

Always be empathic and compassionate, but know that for lots of people it's a business transaction, and their attachment to you is fickle and it's a generational thing. Be ok with it. 

The strength of a loving hand

 I don't remember how long I spent with grandma and you in the village. I would have been about 9 and should have been enrolled in school but somewhat I wasn't. I have patched recollections of the time spent with grandma and gandpa but none of that helps bring the day to day memories back. Other people tell me that yes indeed I was there and that they had to go shopping for me. They had no sweets, they were my cousins, they were slightly older than I was and in one case a few months younger. How can I ask for forgiveness when I wasn't aware of the reality that was going on. Where was my mind, my conscience? Did I not see that they had no rights to sugar and that they were obligated to get if for me, with no percentage to go to their own sweet teeth? Did I not look at the cravings in their eyes, their mouths, their bellies. I cannot condemn an act that I am not conscious of or can I? A few months later, we were to join my father in France and we were to go on the great adventure. We were to cross the river and if anyone gets visions of crossing the Rio Grand or running through the Sonora Desert, let the thought be put to rest that this was a mere creek and everyone was in on it. Portugal wanted, as it does now for its people to go and emigrate. They would ship money home, they would have jobs that were actually available at home but somehow they did not have the technical know how for and the state would be getting rid of the many mumblings that grew louder by the day. So crossing the river in the Northern part of Portugal was not at all like crossing the Rio Grande. But the fear was there and so was my mother's hand. It was with she that I went. We were to join father, already in Clermont Ferrand, on the Massif Central of France where Michelin had its headquarters. My father would pay dearly for this job many years later but as it was, he benefited from vacations, payed, can you believe that?He wold be able to bring his wife and child. They took no responsibility for how they (us) got there ,but once there, I was given the choice of presents at Christmas, already disappointing my parents by choosing a bunk bed over a sawing machine! But I knew why I wanted the bunk bed. I dreamt that I would get more dolls and they would need to sleep somewhere whereas if I got a sawing machine I would be obligated to do what my mother did which was saw clothes. She hated it so much I figured it must have been a tedious endeavor. She never spoke one way or the other. But now, I am getting ahead of myself, as the tale I want to tell concerns my jumping the river, in this case a tiny creek located in the Northeast of Portugal. father had paid for the transportation by bus to the nearest village and many or a few I do not recall people, mostly women and children and a few men, would join up with the man that would get us across. It was a a joke of sorts. But you paid for the risk it was supposed to be. The communist leader, Alvaro Cunhal, wrote of this many years later under the pseudonym of ManuelTiago. You can't be the communist leader and have artistic tendencies, although plenty he had. Many years later I sat mesmerized listening to an 89 year old man talking about art for three hours with not so much a mention of straight out politics. I bought a series of serigraphs which I should have better taken care of.  Back to the Northeast and it is time to get off the bus cross the creek, be on the watch out for the farce of the police  and make our way to the nearest train station where we would go directly to the city indicated in our ticket no questions asked. The French were reconstructing the country and they wanted people there and if they came from Portugal the better,. The crossing was tremendously scary and 30 years later I took an art and drew a woman holding a child's hand, as they are on the edge of a creek, with a dark, gloomy and utterly inartistic forest on the other side. The creek was agitated and had many boulders. It took many more years to figure that it wasn't my daughter and me but actually the moment where once again the hand of my mother's hand prevailed. The fear, the anxiety, we were one and we took the jump. I do not remember anything more but again I do remember my mother's fear and my fear both transfigured and increased, but with the assurance that mother provided, her warm hand transmitted, all would be well. It was and we got safely to the place father had rented, of which I will speak later. I still have the need of the feeling that our hearts beat as one at the moment of the crossing, looking around for the para military police, waiting for what, wondering about what. Fear was my mother's, I was somewhat bemused but became very scared when I felt her hand grabbing mine for dear life, as I'd felt before. The hand, always the hand!

Why did you leave your place of birth, I asked

 On migrations and heartbreaks

My father disliked this country from the moment he landed at JFK in the now distant year of 1974. His, was a golden opportunity, one he never enjoyed and fully took advantage of. He was given a partnership in a business, in a city that was bustling with growth, Washington DC. As he also often said, he could have returned to his country of birth with duffle bags full of money. He did well, but he never did as well as many others with the same opportunities. This was a hospitable country, one of opportunities and coming from a recently freed from

fascism Portugal, a country of small minds and smaller pockets, this was indeed the land of riches. Yet something lacked. His family, his sisters and nieces, his hometown, above all his hometown, a small city up in the Northern part of Portugal. His identity was emmeshed with a town he had left at the age of 18 to go into the army. 

He left the town but the memories never left him. He would return almost yearly, joyful, walking to his sister's house, seeing old friends, driving to the farm and to other localities and he felt in his element. He always returned and only then, would he rest and find some tranquility.  He did not have pleasant childhood memories, indeed they were of a kind that you mostly read about now. Wanting to study, there was no money for the exams, loving his mother above all, he saw her lead a life of poverty and sadness, one of loss and heartbreak. Seeing his brothers drink, he resolved to never do it.  

No, memories of a golden childhood he did not possess. But his compass was turned to that land and it drew him like a homing pigeon whenever he could break away. He left this country as soon as he could and settled for the rest of his life in the town that saw him born. He kept Portuguese time, followed the phases of the moon, his only religion, and always knew what time the sun set, wherever he was, to the minute, to the second. The sky was his reference, the same sky he had in that other place. 

America can be good, but I would bet that were it not for the opportunities, many people would do as my father did and return or never set foot here again. When I speak of America, I speak of many wealthy countries people are driven to, out of necessity, and often sheer desperation. Would they could choose, they would stay, stay in their communities, surrounded by family and old habits, by familiar tongues and foods. By the color of the sky and the familiar skyline. Most, would indeed do with a little less but with a sense of home. A little less is not famine, war, rape, torture and natural disasters. 

So, again, the world is in a mad flux, as it had not been since the beginning of the 20th century. Displacement is the word of the day, people taking to routes, deserts and seas, subject to merchants of death, attempting to escape a vile destiny. Arrived at the land of milk and honey, they work long hours and do the lowest biddings, they don't understand the languages and they sacrifice lives meant to to borne out in toil. 

Those are the refugees, the peasants and the poor, the war ravaged poor, of the poorest countries, or the unlucky ones who serve as proxies for empires. Migration is not limited to those, though. There are restless souls and odd marriages, love and other callings. And to those, the pain of leaving what you know behind, also leaves a hole in the chest and a sadness of longing. We are by nature a peoples on the move, and have been so since the beginning of time. We spread out to all continents, we made our way to the Northernmost Pole and the Southernmost islands. But we did so throughout millennia, time barely moving. Industrialization changed all of that and before then, the great movements of ships during the times of Magellan, Vasco da Gama and of course Columbus. The Mongols transversed Asia and the Macedonians reversed the way. People have been in flux for millennia, it's true, but never has this worldwide movement of migrations to and forth, this restlessness brought out by an unregulated globalization that has uprooted most people, and disconnected us from our ancestors, our familiar birth sky colors, familiar skylines and sights. Never have so many felt so lost and so homesick. COVID brought an added desperation, and a stop to the frenzied tourism, which restlessly awaits its degrading and destructive paths. I love my country, I love my countries, I have one foot in this great America, with deserts and soaring mountains, deep forests and vast plains, this country so vast and so wild and so untamed...I also miss my little corner on the western most part of Europe, a small, old and almost unknown country, that many think is part of the bigger neighbor to the East. It almost is. It's tiny and it's mostly coastal, friendly and as it was to my father, it is in the end, the one I really call home. 

I get immigration, I get emigration, I get displacement and I also get what  it can represent to many. I get it because I have been a student of it. I have spoken, written and read on what makes someone get up and leave the familiar. It is often the first question out of my mouth, where are you from and why did you leave. 

I mostly get it though, because it has made me suffer so...

on holidays and ritual

Rituals provide meaning and place. Habitually they provide solace. Rituals, religious and nationalistic in character provide belonging, expansions from the needed survival of the tribe. We all know that. Anthropology 101. So, when society and tribe are bound for destruction because of the attachment to those same rituals, when do we rethink the rituals and where and who manifests where we went so wrong?
This is the little piece for thought that I intend on concluding in the next few days. There will be no quotations, and I will not be looking up the Foucaults' and Levy-Strauss' of the generation of subjectivity. I will go on instinct and passion, to better understand those who still follow instinct and passion.
My patient and I engage in a dance, one that I have engaged in a thousand times before. He bargains, I plead, I buy time I fear. Nobody wins. For he is in the clenches of a Major God who punishes him for eating where others have no food. His ethics clash with his survival. His death will mean the death of his ethics. But he cannot bring himself to eat. He reasons and he justifies and above all he refuses or cannot face the truth. But what is truth.
Eating disorders and addiction disorders resemble each other in ways that are hard to fathom. Each has a beginning, as we, the tribe of healers  try to avoid the ending. The beginnings are all different, the endings are all equal, all ending in the great equalizer that is death, a pre-announced and pre-lived death, a death lived in full knowledge that it will come at any time, but the price is night. For life does not have such high a price for those who dwell in misery. That is what we, the other ones, the half living, half dead think, Death brings peace and the end to torture and is welcomed always, and we, the healers, try to stave it away, from them as much as we try to stave it away from ourselves.

A Pandemic Psychosis (Written in June, 2020)

 

A pandemic psychosis

Two months into the pandemic, when the city was empty, fear had cloaked everyone’s soul, and we all lived by the skin of our teeth, holding on to our loved ones and to our little worlds. After being sent home to tend to our patients from the distance of our phones and a few through the strangeness of a screen, we returned to work, to the hospital, to our small offices. To the offices that a new kind of patient came in. At first, they trickled in, one by one, from Honduras, Mexico, the islands, all women, all mothers, all saying the same, describing the same phenomenon. They were scared, they were anxious, and they were falling apart. The diagnoses were all depression and anxiety, severe anxiety, with one additional feature, psychosis. Fear was driving them mad. The fear that clutches the chest at 3 am, the all-consuming heart eviscerating fear which was bringing these women to the clinic for the first time in their lives.

They had managed, overcome really, childhoods of poverty hard to imagine, had travelled long weeks from small villages to the biggest metropolis in the country, managed oppressive bosses and low paying jobs, and the many, many small and large insults to their dignity and to their psyches. They had been involved with men who wanted an easy lay, grabbed them, brought their once courageous capabilities to naught. As they watched death cover the city, when the dark heavy fog that crept into houses and took one here, one there, as they lay in bed shivering with Tylenol and little else, isolating in small, crowded apartments, small rooms, where quarantining is impossible, the thoughts took hold.

This miasma, what was this, that they could succumb to, this flu that made some laugh and took others’ essential breath away. Alone, crowded but alone, they, for the first time saw death staring them down, lives cut short by a senseless and mysterious disease that had come from the bowels of China, brought devastation to Europe, and settled in this city they now called their own. The city that never sleeps went dark, the streets empty, tourists gone, Times Square vacated.

In the endless nights of chills and pains, and fear, they met death at their doorsteps and started to fall apart. They foresaw their children, their little ones, abandoned to family members, neighbors, roommates, alone, returning to worlds they had never known and to which they would never belong. They saw their children become who they had been; hungry, violated, and they found the possibility unbearable. For it was a very real possibility, their fate intertwined with their children’s. They clung, they cried and let their souls and courage set loose and be taken as a bargain for an extension of life, for a chance to guide their children through a few more years of life lived in small, shared rooms, with side gigs and side jobs, teaching their children hurried lessons in life, let they have to take leave to never return. Like them, these babes were helpless and such sweet temptation to the claws of the men who had brought them down and from whom they had escaped.

They did not cry. They did not complain. They suffered until they could no more. And what had been a trickle became a steady pilgrimage, the new holy centers, the clinics that saw them for free and would try to make them whole again. For in this mad, diseased, enclosed and empty city, not even the churches would harbor them. To the mental health center they came, at first, a trickle, and then a steady growing invasion that became apparent to the “healers” who were still standing and had better resources and nicer houses.

They smiled through their hollow eyes that they thought only they could see, spoke of fears for their children. And then they fell apart, fragmented, broken, desolate. They spoke of death, of loneliness, of long lives that felt empty of meaning, shattered common pieces of humanity that we were expected to scoop up and put together again with our soothing cooing sounds and round colored little pills, which they devotionally took as a new manifestation of revelation, wafers of salvation, replacing what in their most acute and cruelest moment of need, abandoned them for the sake of the body politic that knew not where it was drifting. If, it was drifting. But death, this they knew was lurking under every lit door.

Those who could, and many did, left for country houses where isolation was luxurious, green and lush and devoid of danger; new opportunities, actually. For these women, their one-time maids and servants, lost income, no possibility, no opportunity except at the long lines in schools and food pantries for the necessities that would become their salvation. Rations, that that they knew little to do with, Americanized diets to bodies used to tamales and cans of dark frijoles, replaced by flaccid canned green beans and canned tomatoes and lots of pasta, as if they had all just gotten off the boat from Italy and the past was the other one, the one that ravaged with more wanton and merriment joining with the war that would feed another one.

The quiet Pandemic of 2020 did not touch the elites and poor decisions were made by greedy and witless politicians.

Ah, yes, the women… the mad Latina mothers brought down by this pandemic, survivors due to their youth and hard lean bodies, bodies used to hard physical labor. Not slouches, not obese, these domestic workers, cleaning their rooms and the big houses of the wealthy, some so big that they would be told to harbor their isolation/quarantine in some dark and fetid humid corner of the basement with scraps left at their door, food strange to their palates and no remedies. There were no remedies. Only the last, desperate, violent and violating thrust of a cold metal hose of a ventilator down their throats, and into the soft tissues of lungs untouched by cigarettes or the other byproducts of modernity, with the exception of car fumes of which there were no more. Highways devoid of cars, streets dirty, but silent, skies no longer crisscrossed by planes full of the people they would never be. But their daughters? There was hope and this hope was dashed again and again, day by day, week by week.

Most survived and smiled when told that they were for the most part young enough to make it, that this was a killer of the old, and the unwell and the extremeobese. Most were not. A few sessions were all it took, a few sessions of humanity and plain talk, of mutual reassurance that this would come to a quick end. Most after a short period, were able to work, and no longer had time for the new healers that had soothed their fears with some kind words and a few temporary pills.

Postscript:

Little did we know that a year later, there are still people, mostly the elderly and the ill, who can’t go out, who cannot touch their family members, who cannot celebrate Holidays and Festivals. Masks are worn and hands are washed as if we all became surgeons about to go in. A few made out like bandits and most lost much of what they had.

 

A Clinical Social Worker’s Bane.

I woke up to a grey Saturday, the sky, a pane of dullish ashen, the sound of planes going towards La Guardia or Kennedy, descending bellow the cloud line, as they approached their destinations. The street was quiet from the dining room table at which I wrote, the constant “hum” from highway 278, a block away, only heard from the other side of the apartment. In the house, all slept and I got up to complete some notes, an unending and infernal part of my job, the clichéd, yet so apropos “bane of my existence”.

I am a clinical social worker at a hospital’s mental health clinic situated in Brooklyn, a non-profit, still somewhat independent, a unique institution with no formal affiliation. This makes little difference, I know, for I speak to other clinicians who practice at other hospitals, private, public and city run. It matters little. We have all become assembly line workers in the factory of mental health.

I completed the three short notes, from a week before, lest they “lock”. When they lock, it sets in a process, an obligatory reminder email, from one of the managers, “cc’d” to at least five other people, all supposedly important, all with laden titles, full of acronyms whose meanings are unknown to all, but the proprietor, yet add gravitas to a name and a role in the factory.  As I was writing, after a well-rested night, with the day full of promises ahead of me, I realized that the content, the depth and the writing were unlike that of most other blurbs, that provide a summary of a person’s mental status. No hasty, badly composed sentences, repeated ad nauseum, a sort of rubber stamp to ensure that the hospital is reimbursed for a patient’s psychotherapeutic visit.

As a clinical social worker, I spend 30 or 45 minutes with individuals and using various methodologies, I attempt to bring solace, clarification or just provide some company to the many troubled souls that struggle to rid themselves of daemons, bad choices, and bad marriages, mean children and mean parents, poverty, and racial, gender and legal oppression. I am humbled to be the trustee of horror stories and strive to lighten the load of trauma and misery. Each individual a universe, unique and rich in diversity and exceptionality, each encounter a rich tapestry of interwoven tales, brought to life by their words, at times almost poetic and lyrical, most often devoid of joy, devoid of life. I put much effort into comprehending and grasping the full of the person’s potential as well as possibilities. I toil to fulfill the other responsibilities, the bureaucratic drudgery, the clicking of endless buttons on a form, the phone calls, the emails, the forms.

I am a unionized clinical social worker, paid to work 35 hours a week, with two 15-minute breaks and one-hour lunch. That’s the hypothetical, the agreement between my union and the hospital. Yet, I take no such small breaks, eat a harried and hurried lunch when I eat at all, and carry a load of on average 100 people, for whose lives I am partially responsible. I see them at the clinic but inevitably bring home  paperwork to complete. At the facility, I put in at least 50 hours and live with a constant dread of not having clicked a button, of not having made another phone call, of overlooking the sadness in someone’s eyes, of not fully paying attention, of not having been totally and completely present and mindful. I write rushed notes, just the obligatory, no depth, no conveyance of the interaction that just transpired. My mental health and that of many of my colleagues becomes compromised, the risk of burnout or empathy fatigue is high, yet the machine hums along. Every day, every hour, I strive to provide the best clinical and empathic care. Nonetheless, I am always behind on paper work, risking disciplinary actions. No one speaks of the quality of the work, as it’s all about quantity. I am privileged to work with a mostly exceptional group of professionals, and I love what I do. I have also been witness to shoddy and rushed work, clients who deserve better but don’t know what to expect.

The turnover rate in psychiatry is very high, where constancy is most needed. We appear surprised when sequential Wars on Drugs and on Depression and on Obesity are wars lost. We do not invest in prevention and we run the workers into the ground. Mental health work is not valued in this city, it is not valued in this country. Yet, this is a profoundly unwell society and the signs abound. Mental health cannot be run on Fordism, with increased production, in less time and with less resources. There are plenty of resources, but they are all going to the pharmaceutical companies who charge 10 times as much for the same medications in this country as they charge in the European Union and other parts of the world. We have vice presidents of vice presidents, sub-directors of sub directors. We have more bean counters than we have beans. We are overseen by so many agencies that most clinicians do not know who does what, when, and how. Those too, are profligate with acronyms. Our mental health system is very ill, and the people who most suffer are those who most need it. Anytime, you hear of how many people died from overdoses or from suicide, look up a few statistics. Connect the dots. Follow the money. 

By the way, in way of clarification, my license does not protect me. I have a license so that the clients are protected.

Manuela P. Mage, Woman, Mother, Jewish, Companion, Social Worker, World Citizen, Friend, Reader…