While depression is a terrible burden on its own, it is even more traumatic for those with multiple physical and psychological illnesses. Most of the indigent depressed suffer physical symptoms and are prone to attacks on their exhausted immune systems. If it is difficult to help someone who is depressed to believe that a miserable life and the depression are separable, it is even more difficult to convince someone with the burden of mortal illness that his despondency can be treated. In fact, distress over pain, distress over bleak life circumstances, and a distress without object can be disentangled, and an improvement in one arena in turn eases the others.
When Sheila Hernandez arrived at Johns Hopkins, she was, according to her physician, “virtually dead.” She had HIV, endocarditis, and pneumonia. Constant use of heroin and cocaine had so affected her circulation that she couldn’t use her legs. Doctors gave her a Hickman catheter, hoping through IV feeding to build up enough physical strength so that she could withstand treatment for her infections. “I told them to take this out of me, I’m not gonna stay,” she recounted to me when we met. “I said, ‘I’ll leave with this thing in me if I have to and I’ll use it to put the drugs in.’ ” At that point, Glenn Treisman came to see her. She told him she didn’t want to talk to him since she was dying soon and leaving the hospital sooner. “Oh no you’re not,” Treisman said. “You’re not heading out of this place to go and die a stupid, useless death out on the streets. That’s a crazy idea you have. That’s the nuttiest thing I ever heard. You’re going to stay here and get off those drugs and get over all these infections of yours, and if the only way I can keep you in here is to declare you dangerously insane, then that’s what I’ll do.”
Sheila stayed. “I went into the hospital on April fifteenth, 1994,” she told me, cackling ironically, crisply. “I didn’t even see myself as a human being then. Even as a child I remember feeling really alone. The drugs came into play as far as me trying to get rid of that inner pain. My mother gave me away when I was three to some strangers, a man and a lady, and the man molested me when I was around fourteen. A lot of painful things happened to me, and I just wanted to forget. I would wake up in the mornings and just be angry that I woke up. I felt like there wasn’t any help for me, ’cause I was just on this earth wasting space. I lived to use drugs and used drugs to live, and since the drugs made me even more depressed, I just wanted to be dead.”
Sheila Hernandez was in the hospital for thirty-two days and went through physical rehabilitation and treatments for her addiction. She was put on antidepressants. “It turned out that all what I felt before I went in, I found it was wrong. These doctors told me I had this to offer and that to offer, I was worth something after all. It was like being born all over again.” Sheila dropped her voice. “I’m not a religious person, never was, but it was a resurrection, like what happened to Jesus Christ. I came alive for the first time. The day I left, I heard birds singing, and do you know I’d never heard them before? I didn’t know until that day that birds sang. For the first time I smelled the grass and the flowers and—even the sky was new. I had never paid any attention to the clouds, you know.”
Sheila’s younger daughter, who was sixteen and already had her first baby, had dropped out of school a few years earlier. “I saw her going on a painful road I knew,” Sheila says. “I saved her from that, at least. She got her GED, and now she’s a sophomore in college, and she’s also a certified nursing assistant working at Churchill Hospital. It wasn’t as easy with the older one, she was already twenty, but finally she’s in college now too.” Sheila Hernandez never took drugs again. Within a few months, she returned to Hopkins—as a hospital administrator. She did advocacy work during a clinical study of tuberculosis, and she secured permanent housing for the study’s participants. “My life is so different. I do these things to help other people all the time, and you know I really enjoy that.” Sheila’s physical health was now excellent. Though she was still HIV-positive, her T cells had doubled and her viral load was undetectable. She had residual emphysema, but after a year on oxygen, she managed on her own. “I don’t feel like anything is wrong with me,” she announced cheerily. “I’m forty-six, and I’m planning on being around here for a good long time. Life’s life, but I would say that, most of the time at least, I’m happy, and every day I thank God and Dr. Treisman that I’m living.”
After I met Sheila Hernandez, I went upstairs with Glenn Treisman to see his notes on her original admission: “Multiple disorders, traumatized, self-destructive, suicidal, depression or bipolar illness, physically a complete wreck. Unlikely to live long; extreme rooted problems may prevent response to existing treatment strategies.” What he had written seemed utterly incommensurate with the woman I’d met. “It looked pretty hopeless then,” he said, “but I thought it was necessary to try.”
Despite the extended debates in the last decade about depression’s causes, it seems fairly clear that it is usually the consequence of a genetic vulnerability activated by external stress. Checking for depression among the indigent is like checking for emphysema among coal miners. “The traumas in this whole culture are so terrible and so frequent,” Jeanne Miranda explains, “that even the most mild vulnerability is likely to get triggered. These people experience frequent intrusive, unexpected, sudden violence, and they have very limited resources for dealing with it. What is surprising when you examine lives so full of psychosocial risk factors is that at least a quarter of the population is not depressed.” The New England Journal of Medicine has acknowledged a connection between “sustained economic hardship” and depression; and the depression rate among the indigent is the highest of any class in the United States. And people who are without resources are less able to rebound from adverse life events. “Depression is highly related to social opposition,” says George Brown, who has worked on the social factors that determine mental states. “Deprivation and poverty will do you in.” Depression is so common in indigent communities that many people don’t notice or question it. “If this is how all your friends are,” says Miranda, “it has a certain terrible normality to it. And you attribute your pain to external things, and believing that these externals can’t change, you assume that nothing internal can change.” Like all other people, the poor develop, with repeated episodes, an organic dysfunction that runs by its own rules on its own course. Treatment without attention to the actual lives of this population is unlikely to be successful; drawing someone through the biological chaos that has stemmed from repeated traumas does little good if that person is going to be retraumatized constantly for the rest of his life. While people who are not depressed are sometimes able to muster their meager resources to change their position and escape some of the difficulty that characterizes their life, people who are depressed have a hard time maintaining their place in the social order, much less improving it. So the poor require novel approaches.
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 h
er 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 m
e 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.”
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