It is hard to make specific numerical estimates of the costs associated with serving this population, but 13.7 percent of Americans are below the poverty line, and according to one recent study, about 42 percent of heads of households receiving Aid to Families with Dependent Children (AFDC) meet the criteria for clinical depression—more than twice the national average. A staggering 53 percent of pregnant welfare mothers meet the same criteria. From the other side, those with psychiatric disorders are 38 percent more likely to receive welfare than are those without. Our failure to identify and treat the indigent depressed is not only cruel but also expensive. Mathematica Policy Research, Inc., an organization that compiles social-issue statistics, confirms that “a substantial proportion of the welfare population . . . have undiagnosed and/or untreated mental health conditions,” and that offering services to these individuals would “enhance their employability.” State and federal governments spend roughly $20 billion per year on cash transfers to poor nonelderly adults and their children. We spend roughly the same amount for food stamps for such families. If one makes the conservative estimate that 25 percent of people on welfare are depressed, that half of them could be treated successfully, and that of that percentage two-thirds could return to productive work, at least part-time, factoring in treatment costs, that could still reduce welfare costs by as much as 8 percent—a savings of roughly $3.5 billion per year. Because the U.S. government also provides health care and other services to such families, the true savings could be substantially higher. At the moment, welfare officers do no systematic screening for depression; welfare programs are essentially run by administrators who do little social work. What tends to be described in welfare reports as apparently willful noncompliance is in many instances motivated by psychiatric trouble. While liberal politicians tend to emphasize that a class of miserable poor people is the inevitable consequence of a laissez-faire economy (and is therefore not subject to rectification through mental health interventions), right-wingers tend to see the problem as one of laziness (which is therefore not subject to rectification through mental health interventions). In fact, for many of the poor, the problem is neither the absence of employment opportunities nor the absence of motivation toward employment, but rather severe mental health handicaps that make employment impossible.
Some pilot studies are under way on depression among the indigent. A number of doctors who work in public health settings are accustomed to addressing this population, and they have shown that the problems of the indigent depressed are manageable. Jeanne Miranda, a psychologist at Georgetown University, has for twenty years been advocating sound mental health care for inner-city residents. She recently completed a treatment study of women in Prince George’s County, Maryland, a poverty-stricken district outside Washington, D.C. Since the services of family planning clinics are the only medical care available to the indigent population in Maryland, Miranda selected one for random screenings for depression. She then enrolled those whom she judged to be depressed in a treatment protocol to address their mental health needs. Emily Hauenstein, of the University of Virginia, has recently conducted a treatment study of depression among rural women. She began researching troubled children and moved on to treating their mothers. She based her work in Buckingham County in rural Virginia—where most jobs are at prisons or in a few factories, where a good part of the population is illiterate, where a quarter of the population has no access to a telephone, where many people live in substandard housing with no insulation, no indoor toilet, frequently not even running water. Both Miranda and Hauenstein screened substance abusers out of their protocols, referring them to rehabilitation programs. Glenn Treisman, of the Johns Hopkins University Hospital, has for decades been studying and treating depression among indigent HIV-positive and AIDS populations in Baltimore, most of whom are also substance abusers. He has become both a treating clinician and an outspoken advocate for this population. Each of these doctors uses techniques of tenacious care. In all of this work, the per patient per year cost is well under $1,000.
The results of these studies are surprisingly consistent. I was given full access to patients in all of these studies, and to my surprise, everyone I met believed that his or her life had improved at least a bit during treatment. All those who had recovered from severe depression, no matter how dreadful their circumstances, had begun the slow climb toward functioning. They felt better about their lives and also lived better. They had been introduced to agency and had begun to exercise it; even when they were up against nearly insurmountable obstacles, they progressed—often fast, and sometimes far. The horrible stories of their lives were way beyond anything I had anticipated, so much so that I repeatedly checked the stories with their treating doctors, asking whether they could really be accurate. So too were their Cinderella-like stories of recovery, as lovely as the one with the pumpkin coach and the glass slipper. Over and over again, as I met poor people who were being treated for depression, I heard tones of astonishment and wonder: How, after so many things had gone wrong, had they been swept up by this help that had changed their entire life? “I asked the Lord to send me an angel,” said one woman, “and he answered my prayers.”
When Lolly Washington—who was part of Jeanne Miranda’s study—was six, a disabled friend of her alcoholic grandmother’s began abusing her sexually. In seventh grade, “I felt there was no reason to go on. I did my schoolwork and everything, but I was not happy in any way.” Lolly began to withdraw. “I would just stay to myself. Everyone thought I couldn’t talk for a while, because for a few years there I wouldn’t say anything to no one.” Like many victims of abuse, Lolly believed herself to be ugly and unfit. Her first boyfriend was physically and verbally brutal, and after the birth of her first child, when she was seventeen, she managed to “escape from him, I don’t know how.” A few months later she was out with her sister and her cousin and her cousin’s child and an old family friend “who was always just a friend, a really good friend. We were in his house, all of us, and I knew his mom kept pretty flower arrangements on her dresser. So I went to look at them because I loved flowers. And then suddenly, somehow everybody in the house was gone, and I didn’t know. He raped me, violent, and I was screaming and hollering and no one answered. Then we went downstairs and we got into the car with my sister. I couldn’t speak, I was so afraid, and bleeding.”
Lolly became pregnant with and bore the rape baby. Soon after, she met another man and under family pressure married him even though he too was abusive. “My whole wedding day was not right,” she told me. “It was like going to a funeral. But he was the best option I had.” She had three more children by him in the next two and a half years. “He was abusing the children too, even though he was the one who wanted them, cursing and yelling all the time, and the spankings, I couldn’t take that, over any little thing, and I couldn’t protect them from it.”
Lolly began to experience major depression. “I’d had a job but I had to quit because I just couldn’t do it. I didn’t want to get out of bed and I felt like there was no reason to do anything. I’m already small and I was losing more and more weight. I wouldn’t get up to eat or anything. I just didn’t care. Sometimes I would sit and just cry, cry, cry. Over nothing. Just cry. I just wanted to be by myself. My mom helped with the kids, even after she got her leg amputated, which her best friend accidentally shot off around then. I had nothing to say to my own children. After they left the house, I would get in bed with the door locked. I feared when they came home, three o’clock, and it just came so fast. My husband was telling me I was stupid, I was dumb, I was ugly. My sister has a problem with crack cocaine, and she has six kids, and I had to deal with the two little ones, one of them was born sick from the drugs. I was tired. I was just so tired.” Lolly began to take pills, mostly painkillers. “It could be Tylenol or anything for pain, a lot of it though, or anything I could get to put me to sleep.”
Finally one day, in an unusual show of energy, Lolly went to the family plan
ning clinic to get a tubal ligation. At twenty-eight, she was responsible for eleven children, and the thought of another one petrified her. She happened to go in when Jeanne Miranda was screening for study subjects. “She was definitely depressed, about as depressed as anyone I’d ever seen,” recalls Miranda, who swiftly put Lolly into group therapy. “They told me I was ‘depressed,’ and that was a relief, to know there was something specific wrong,” Lolly says. “They asked me to come to a meeting, and that was so hard. I didn’t talk when I went there, but I just cried the whole time.” Psychiatric wisdom holds that you can help only those who want to be helped and will keep their appointments themselves, but this is ostentatiously untrue in these populations. “Then they kept calling, telling me to come, pestering and insisting, like they wouldn’t let go. They even came and got me at my house once. I didn’t like the first meetings. But I listened to the other women and realized that they had the same problems I was having, and I began to tell them things, I’d never told anyone those things. And the therapist asked us all these questions to change how we thought. And I just felt myself changing, and I began to get stronger. Everyone began to notice I was coming in with a different attitude.”
Two months later, Lolly told her husband that she was leaving. She tried to get her sister into rehab, and when she refused, Lolly cut her off. “I had to get rid of them two who were pulling me down. There was no arguing because I just didn’t argue back. My husband was trying to get me out of the group because he didn’t like the change in me. I just told him, ‘I’m gone.’ I was so strong, I was so happy. I went outside to walk, for the first time in so long, just making time for my happiness.” It took two more months for Lolly to find a job, working in child care for the U.S. Navy. With her new salary, she set up in a new apartment with the children for whom she is responsible, who ranged in age from two to fifteen. “My kids are so much happier. They want to do things all the time now. We talk hours every day, and they are my best friends. As soon as I come in the door, I put my jacket down, purse, and we just get out books and read, doing homework all together and everything. We joke around. We all talk about careers, and before they didn’t even think careers. My eldest wants to go to the air force. One wants to be a firefighter, one a preacher, and one of the girls is gonna be a lawyer! I talk to them about drugs, and they’ve seen my sister, and they keep clean now. They don’t cry like they used to and they don’t fight like they did. I let them know, they can talk to me about anything, I don’t care what it is. I took in my sister’s kids, and the one with the drug problem, he’s getting over it. The doctor said he never expected that boy could be talking so soon, trying to get to the potty, he’s way ahead of where they thought he’d be.
“There’s one room in the new place for the boys and one for the girls and one for me, but they all just like to get up on my bed with me and we’re all sitting around there at night. That’s all I need now, is my kids. I never thought I would get this far. It feels good to be happy. I don’t know how long it’s gonna last, but I sure hope it’s forever. And things keep on changing: the way I dress. The way I look. The way I act. The way I feel. I’m not afraid anymore. I can walk out the door not being afraid. I don’t think those bad feelings are coming back.” Lolly smiled and then shook her head in wonder. “And if it weren’t for Dr. Miranda and that, I’d still be at home in bed, if I was still alive at all.”
The treatments Lolly received did not include psychopharmaceutical intervention and were not closely based on cognitive models. What was it that enabled this metamorphosis? In part, it was simply the steady glow of affectionate attention from the doctors with whom she worked. As Phaly Nuon in Cambodia observed, love and trust can be great justifiers, and the knowledge that someone else cares what happens to you is by itself sufficient to affect profoundly what you do. I was struck by Lolly’s statement that the naming of her complaint as depression had brought her relief. Miranda described Lolly as “clearly” having depression, but this had not been clear to Lolly even when she had suffered extreme symptoms. The labeling of her complaint was an essential step toward her recovery from it. What can be named and described can be contained: the word depression separated Lolly’s illness from her personality. If all the things she disliked in herself could be grouped together as aspects of a disease, that left her good qualities as the “real” Lolly, and it was much easier for her to like this real Lolly, and to turn this real Lolly against the problems that afflicted her. To be given the idea of depression is to master a socially powerful linguistic tool that segregates and empowers the better self to which suffering people aspire. Though the problem of articulation is a universal, it is particularly acute for the indigent, who are starved for this vocabulary—which is why basic tools such as group therapy can be so utterly transforming for them.
Because the poor have limited access to the language of mental illness, their depression is not usually manifest cognitively. They are unlikely to experience intense guilt and to articulate to themselves the perception of personal failure that plays so large a role in middle-class depression. Their complaint is often evident in physical symptoms: sleeplessness and exhaustion, sickness, terror, an inability to relate to others. These in turn make them vulnerable to physical illness; and being ill is often the straw that breaks a camel’s wide back and makes someone with mild depression go over the edge. Insofar as the indigent depressed do get to hospitals, they tend to get there for physical ailments, many of which are symptoms of their mental anguish. “If a poor Latin woman seems depressed,” says Juan López of the University of Michigan, who has done extensive mental health work among poor, depressed Spanish-speaking populations, “I try her on antidepressants. We talk about them as tonics for her general complaints, and when they work, she is delighted. She herself does not experience her condition as psychological.” Lolly too was experiencing her symptoms outside the realm of what she would have perceived to be craziness, and craziness (acute hallucinatory psychosis) was her only model for mental illness. The idea of a debilitating mental illness that was not rendering her incoherent was outside her lexicon.
Ruth Ann Janesson was born in a trailer in rural Virginia and grew up fat with glasses. At seventeen, she got pregnant by a nearly illiterate man who had dropped out of her school, and she cut off her own education to marry him. They had a disastrous marriage; she worked and made ends meet for a while, but after the birth of their second child, she left him. A few years later she married a laborer who operates machinery in a construction yard. She had managed to get a truck-driving license, but within six months her husband had told her that her place was at home taking care of the family and taking care of him. They had had two children. Ruth Ann was trying to make ends meet, “which is hard for a family of six on two hundred dollars a week, even with the food stamps.”
She soon began to drift downward, and by the third year of her second marriage she was losing all signs of vitality. “I had just decided, well, I’m here, I’m existing, and that’s it. I was married, I had children, but I had no life and I was feeling bad basically all the time.” When Ruth Ann’s father died, she “lost it completely,” she said. “That was the bottom. My daddy never beat us, it wasn’t the physical, it was the mental. Even if you’d done good, you never got praise, but you were criticized all the time. I guess I felt that if I couldn’t please him, I couldn’t do anything else. And I felt I’d never managed to please him well enough, and now I wasn’t ever gonna have the chance.” Recounting this period of her life to me, Ruth Ann began to cry, and by the time she finished her story, she had used up an entire box of Kleenex.
Ruth Ann went to bed and mostly stayed there. “I knew something was wrong, but I didn’t put a medical term to it. I had no energy whatsoever. I began gaining more and more weight. I was going through the motions inside our trailer, but I never went out and I stopped communicating totally. Then I realized that I was neglecting my own children. Something had to be done.” Ruth Ann has Crohn’s disease,
and even though she was doing barely anything, she began to get what appeared to be stress-related symptoms. Her doctor, who knew about Emily Hauenstein’s study, recommended her for it. Ruth Ann began taking Paxil and started seeing Marian Kyner, a therapist who worked full-time with the women in Emily Hauenstein’s study. “If it wasn’t for Marian, I probably would’ve just stayed sitting in that same hole I was in until I just stopped living, stopped existing. If it wasn’t for her, I wouldn’t be here today,” Ruth Ann told me, and once more burst into tears. “Marian made me reach inside me, she wanted me to get all the way down to my toes. I found out who I am. I didn’t like it, didn’t like me.”
Ruth Ann calmed herself. “And then the changes began,” she said to me. “They tell me I have a big heart. I didn’t think I had a heart at all, but now I know that it’s there somewhere and eventually I’m gonna find it completely.” Ruth Ann started working again, as a part-time temp for At Work Personnel Service. She soon became office manager and at that point phased out her antidepressants. In January 1998, she and a friend bought out the business, which is a franchise under license from a national company. Ruth Ann began taking night courses in accounting so that she could keep the books well, and she soon recorded an ad for cable TV. “We work with the unemployment office,” she told me, “getting jobs for people who are out of work, placing them in private industry. We train them in our own office, where they help us, and then we send them out with good skills. We’re now covering seventeen counties.” At her heaviest, she weighed 210 pounds. Now she goes to a gym regularly and with intensive dieting is down to 135.
She left her husband, who wanted her to be in the kitchen waiting for him, depressed or not, but she is giving him time to adjust to her new self and when I last saw her was still hoping for a reconciliation. She glowed. “Sometimes a new feeling will hit me,” she said, “and it scares me. It takes me a few days to figure out what it is. But at least I know now that my feelings are there, that they exist.” Ruth Ann had a profoundly new relationship with her children. “I help them with schoolwork at night, and my oldest son decided computers were awesome, and now he’s teaching me how to use them. That’s really helped his confidence. We’ve got him working in the firm this summer, and he’s great. It’s not so long ago that he was complaining of being tired, that he was missing school most days. Until now, the only thing that seemed to motivate him was watching TV and laying on the couch.” Days, she would leave the younger kids with her mother, who is disabled but sufficiently mobile for child care. Ruth Ann soon got a mortgage on a new house. “I am a business owner and a property holder,” she said, smiling. As our interview drew to a close, Ruth Ann produced something from her pocket. “Oh, for heaven’s sake,” she heaved, pressing the buttons on her beeper. “Sixteen calls while I’ve been sitting here!” I wished her luck as she sprinted across the yard to her car. “We made it, you know,” she called just before she got in. “All the way down to my toes, and back again!” She revved the engine, and she was gone.
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