Authors: Andrew Solomon
Trauma among the American indigent is not in general directly connected to the absence of cash. Relatively few of the American poor are starving, but many suffer from learned helplessness, a precursor state of depression. Learned helplessness, studied in the animal world, occurs when an animal is subjected to a painful stimulus in a situation in which neither fight nor flight is possible. The animal will enter a docile state that greatly resembles human depression. The same thing happens to people with little volition; the most troubling condition of American poverty is passivity. As director of inpatient services at Georgetown University Hospital, Joyce Chung worked closely with Miranda. Chung was already seeing a difficult population. “The people whom I generally treat can at least make an appointment and follow through. They understand that they need help, and seek it. The women in our study would never get into my office on their own.” Chung and I were discussing this phenomenon in the elevator at the clinic in Prince George’s County where treatment is given. We got downstairs and found one of Chung’s patients standing inside the glass doors of the clinic, waiting for the taxi that had been called for her three hours earlier. It had not occurred to her that the cab wasn’t coming; it had not occurred to her to try to call the cab company; it had not occurred to her to be mad or frustrated. Chung and I gave her a ride home. “She lives with the father who repeatedly raped her,” says Chung, “because she needs to do that in order to make ends meet. You lose the will to fight for some kinds of change when you’re up against realities like that. We can’t do anything to get her other housing; we can’t do anything about the realities of her life. It’s a lot to handle.”
The simplest practicalities are also enormously difficult for the indigent population. Emily Hauenstein said, “One woman explained that when she has to come to the clinic on Monday, she asks her cousin
Sadie, who asks her brother to come and get her to bring her in, while her sister-in-law’s sister takes care of the kids, except if she gets a job that week, in which case her aunt can cover if she’s in town. Then the patient has to have someone else to come and pick her up, because Sadie’s brother goes to work just after he drops her off. Then if we meet on a Thursday, there’s a whole other cast of characters involved. Either way, they have to cancel about seventy-five percent of the time, leaving her to make last-minute arrangements.” This is just as true in the cities. Lolly Washington missed one appointment the day of a rainstorm because, after arranging child care for the eleven children and clearing her schedule and figuring out everything else, she discovered that she didn’t have an umbrella. She walked five blocks in the pouring rain, waited about ten minutes for a bus, and when she began to shiver from being drenched, turned around and went back home. Miranda and her therapists sometimes drove to the homes of their patients and took them in to group therapy; Marian Kyner arranged to see the women in their homes to save them the difficulty of coming to her. “Sometimes you can’t tell whether it’s resistance to treatment, like you’d assume with a middle-class patient,” Kyner said, “or just too much of a challenge in their life to get it together and keep appointments.”
Joyce Chung said that one of her patients “was so relieved to be called when I did some phone therapy with her. And yet when I asked whether she’d have called me, she said, ‘No.’ Reaching her, having her return my calls—that is
so
hard, and I’ve been ready to give up more than once. She runs out of medication and she does nothing about it. I have to go by her house and give her the refills for her prescriptions. It took a long time for me to understand that her conduct didn’t mean that she didn’t want to come. Her passivity is actually characterological, and not untypical of a person who’s suffered repeated abuse as a child.”
The patient in question, Carlita Lewis, is someone injured all the way to the core. It appears that, in her thirties, she cannot substantially change her life; treatment has really changed only how she feels about her life, but the effect of that change of feeling on the people around her is substantial. As a child and into adolescence, she had a terrible time with her father, until she was big enough to fight back. She dropped out of school when she got pregnant; her daughter, Jasmine, was born with sickle-cell anemia. Carlita has probably had a mood disorder from childhood. “The littlest things would be just
irritating
me, and I’d fly off the handle,” she told me. “I’d pick fights. Sometimes, I was just crying and crying and crying until I got a headache, and then that headache would get so bad I wanted to kill myself.” Her moods easily turned violent; at dinner once, she stabbed one of her brothers in the head with a fork and nearly killed
him. She took overdoses of pills on several occasions. Later in life, her best friend found her after a suicide attempt and said, “You know how much your daughter cares about you. Jasmine don’t have her father in her life, and now she ain’t gonna have her mother. How do you think she will be? She’s gonna be the same way you are if you kill yourself.”
Jeanne Miranda thought Carlita’s problems went well beyond the situational, and she put her on Paxil. Since beginning the medication, Carlita has talked with her sister about what their father did to them, which neither knew the other had experienced. “My sister don’t have anything to do with my father forever,” explained Carlita, who never lets her daughter stay in the house alone with her grandfather. “I couldn’t see my daughter before, sometimes for days, for fear I was gonna take out my moods on her,” Carlita said. “I didn’t want no one to hit her ever, least of all me, and I was always ready to hit her then.”
When sadness hits, Carlita can cope with it. “ ‘What’s wrong, Mama?’ Jasmine asks, and I’m like, ‘Nothing’s wrong, I’m just tired.’ She tries to push it out of you, but then she says, ‘Momma, everything’s gonna be all right, don’t you worry ’bout it,’ and she’ll hold me and kiss me and pat me on my back about it. We have so much love going on between us all the time now.” Given that Jasmine appears to have a natural disposition similar to Carlita’s, this ability to be nurturing without anger signals a great leap forward. “Jasmine says, ‘I’m gonna be just like my mommy,’ and I just say, ‘I hope you don’t,’ and I guess she’s gonna be fine.”
The mechanisms by which one achieves positive change in life are incredibly basic, and most of us learn them in infancy in maternal interactions that demonstrate a link between cause and effect. I have been watching my five godchildren, ages three weeks to nine years. The youngest cries to get attention and food. The two-year-old breaks rules to find out what he can and can’t do. The five-year-old has been told she may paint her room green if she can keep it neat for six months. The seven-year-old has been collecting car magazines and has learned encyclopedically about automobiles. The nine-year-old announced that he did not want to go away to school as his father had done, appealed to parental sentiment and reason, and is now enrolled in a local school instead. Each of them has volition and will grow up with a sense of power. These successful early assertions of power will have far more effect than the relative affluence and intelligence of these children. The absence of a person who can respond to such assertions, even negatively, is cataclysmic. Marian Kyner says, “We had to give some patients lists of feelings and help them understand what a feeling is, so they could know rather than simply repress their emotional life. Then we had to convince them they
could change those feelings. Then we went on to setting goals. For some of these people, the idea even of figuring out what you want and stating it to yourself is revolutionary.” I thought of Phaly Nuon then, who had worked in Cambodia to teach people how to feel after the paralysis of the Khmer Rouge period. I thought of the difficulty of unrecognized feelings. I thought of that mission to attune people to their own minds.
“I sometimes have the feeling that we’re doing sixties consciousness-raising groups in the new millennium,” says Miranda, who herself grew up among the “working poor” in rural Idaho but did not have the “long-term demoralization” she now encounters daily among people who are “unemployed and without pride.”
Danquille Stetson is part of a hard, criminal culture of the rural South. She is African-American amidst racial prejudice and violence, and she feels threat from every side. She carries a handgun. She is a functional illiterate. Danquille’s place, where we talked, is an old, run-down trailer, with the windows blocked shut and every stick of furniture redolent of decay. The only light when I was there came from the TV, which was playing
Planet of the Apes
throughout our conversation. Still, the place was tidy and not unpleasant.
“It’s like a hurt,” she said, first thing as I came in, skipping any introductions. “It’s just like they raking your heart out your body, and it won’t stop, it’s just like somebody’s taking a knife and keep stabbing you all the time.” Danquille was sexually abused by her paternal grandfather when she was a child, and she told her parents. “They really didn’t care, they just swept it right under the rug,” she said, and the abuse went on for years.
It was often difficult to tell what, in Danquille’s mind, was the work of Marian Kyner, what was the work of Paxil, and what was the work of the Lord. “By me getting close to the Lord,” she told me, “He brought me into the depression and out of there too. I done prayed to the Lord for help and He sent me Dr. Marian, and she told me to think more positive and take these pills and I could be saved.” Controlling negative thinking as a way to bring about behavioral change is the essence of cognitive therapy. “I don’t know why my husband, he always hitting me,” Danquille said, pummeling her own arm as she said it, “but after him I just running from man to man looking for love in all the wrong places.”
Danquille’s children are now twenty-four, nineteen, and thirteen. Her biggest revelation in treatment was quite a fundamental one. “I done realized that the things parents do affects the kids. You know? I ain’t been knowing that. And I been doing a lot of things wrong. I put my son through hell, my own boy. If I had of been more understanding—but at the time, I didn’t know. So now I sat down my kids and I say to them, ‘If
anybody come to you and say your mama did this and your mama did this, I’m telling you now it’s true. Don’t do what I done.’ And I told them, ‘Ain’t nothing that bad you can’t come talk to me about.’ And it’s because if I had somebody that would have listened at me and reassured me everything’s gonna be okay, it would’ve been a big difference, I see that now. Your parents don’t realize a lot of your problems come from them,
they
responsible when you begin looking for love in all the wrong places. I know my good friend, I posted his bail when he went shooting his nephew—saw his mother with different men, they made love in the car right there in front of him, and that influenced his life. His mama don’t know that right today. Whatever you do in the dark come to the light in a matter of time.”
Danquille has now become a sort of community resource, teaching friends and strangers her methods for depression control. “A whole lot of people keep asking me, ‘How did you change?’ Since I think positive, I laugh all the time, smile all the time. Now, I had this happen to me, that the Lord started sending people for me to help. I said, ‘Lord, will you give me what they need to hear and help me listening?’ ” Danquille listens to her children now, and she listens to the people she knows at her church. When someone there was suicidal, “I told him, ‘You not by yourself. I was like that.’ And I said, ‘I made it. Ain’t nothing that bad you can’t get through.’ I said, ‘You start thinking positive and I promise you that girl what is leaving you now, she gonna call.’ He told me yesterday, ‘If it wasn’t for you, I would’ve been dead.’ ” Danquille has taken a new place in her family. “I’m breaking a pattern more or less. My nieces, they come to me instead of to their parents, and the pattern of not listening be broken. They say to me, since I been talking to you, I want to live. And I say to everyone, you got a problem, you get help. That’s what God put them doctors here for, to help you. I say that loud with these people, they just dogs eating dog. And anyone can be saved. I had one woman, she drank, smoke, had been with my husband, right with him, no saying she was sorry either, and then with my new friend, but when she come round, I gonna help her, ’cause in order for her to get better she gotta have someone to help her.”
The poverty-stricken depressed are not represented in the statistics on depression because the research those statistics reflect is based primarily on work with people within existing health plans, who are already a middle-class—or at least a working—population. Raising expectations among disadvantaged populations is a tangled issue, and it is true that planting false goals in people’s minds can be dangerous. “I’ll never stop seeing Dr. Chung,” one woman told me confidently, though the actual
parameters of the study had been explained to her over and over. It is heartbreaking that if she were to have another collapse later in life, she will perhaps be unable to get the kind of help that has pulled her through—though all the therapists involved in these studies feel an ethical obligation to provide, paid or not, ongoing basic services to their patients. “To withhold treatment to people who are suffering acutely because it’s going to raise expectations,” says Hauenstein, “well, that’s ignoring the large ethical issue for the sake of the small one. We try our best to give people a set of skills they can use themselves in another situation—to do all we can do to help them stay afloat.” The cost of ongoing medication is an enormous problem. The problem is partly resolved by industry-based programs that distribute antidepressants to the poor, but these barely begin to meet needs. One feisty Pennsylvania doctor I met told me that she got “truckfuls of samples” from pharmaceutical salesmen to give to her indigent patients. “I tell ’em that I’ll use their product as my first-line treatment on patients who can pay and who are likely to renew over a lifetime,” she said. “In exchange, I tell ’em I’ll need a more or less unlimited supply of product so that I can medicate my low-income patients for free. I write a hell of a lot of prescriptions. The smart salesmen always say yes.”