Читать книгу This City Is Killing Me - Jonathan Foiles - Страница 9

CHAPTER 1

JACQUELINE

When I first met Jacqueline, she was trying very hard to hide in our waiting room. She was wearing large Jackie Kennedy-style sunglasses, and the frayed hood of her hoodie was cinched tightly around her face despite the summer heat. She was wearing gray sweatpants, the cuffs of which were ragged and dingy from dragging on the ground behind her flip flops. Her head was tilted downward, her gaze focused tightly on a spot about six inches in front of her toes. Her mental health assessment noted that she was a transgender woman, but the intake worker did not ask her for her real name. I called out her last name like a drill sergeant and asked her to follow me back to my office.

I was excited but nervous to begin treating Jacqueline. She was the first patient I had seen with borderline personality disorder, and I had heard horror stories from other professionals about working with that population. She was also the first trans patient I treated. I had no special training in trans health or treating LGBTQ populations, but I was trans-affirming and thought I could help her. Looking back, I think I was also trying to atone for the homophobia and transphobia that had shaded my conservative Midwestern upbringing.

In my office, I try to create a safe space that comforts the patient. Plants line my shelves, and I have various art prints hanging on the wall, all in muted colors. I keep my lights low. I noticed that Jacqueline continued to keep her sunglasses on her face even though I felt certain she could barely see a thing. She had come ready to begin treatment; she had already called my supervisor several times asking to be connected with an individual therapist. She wasted no time in telling me about her traumatic past. About twenty years ago she was on vacation in her native Brazil visiting her family. At that time she was living as a gay man. She went to a local bar and had a little too much to drink. She met someone and decided to go home with him. He offered to drive her back to his place, and since she had walked to the club she accepted. Due to the lingering effects of the alcohol, the blindness of lust, or both, she didn’t pay attention to where he was going. She noticed when he stopped in the middle of the field, reached behind him, and pulled out a machete. Her senses sharpened, she wrenched open the door and began running for her life. She ran through unfamiliar terrain for an hour and a half until dawn when a stranger let her use their phone.

I often ask patients when they thought their problems started. I do this not because their answer is necessarily correct, but it gives me a sense of how they think of their symptoms. Jacqueline traced the source of her mental suffering back to that day. It wasn’t hard for me to see why Jacqueline felt that this marked the commencement of her downward spiral. Before then she had lived a decently fulfilling life as a gay man. She had friends, she spent most of her time in Boystown, the historically LGBTQ neighborhood in Chicago, and she was active in the dating scene. Inside she knew that she felt like a woman, and she only really felt comfortable in her own skin when she was performing her drag routine, but she didn’t yet know what it was to be transgender.

As I grew to know Jacqueline better I found out that things before the attempted murder weren’t quite so sunny as she remembered. She felt immense pressure during high school to act hypermasculine. This grew to be exhausting, and she finally came out as gay to her parents when she was sixteen. According to her they were shocked, but she later told me that one of the first English words her immigrant father learned (and then deployed liberally) was “faggot,” so I assume they suspected something. Regardless, they kicked her out that night. Jacqueline rarely had to sleep on the streets, but sleeping on couches and floors is still no way to live. She worked to make something of herself. She completed a year of college. Later her relationship with her parents healed somewhat, and she was invited back into their circle. She tended to gloss over all of this in session; she lived with her mother and saw her father regularly and reported all was well. I wanted to believe this for her sake, but the wounds of our past often don’t heal as quickly as we would like.

Jacqueline’s pain didn’t end with her parents. During her twenties she was reasonably well-integrated in Chicago’s LGBTQ scene, and from what she told me it sounded like she had strong friendships. Her romantic relationships were a different story. Nearly every previous boyfriend she recounted to me had abused her in some way—physically, sexually, emotionally, or all of the above. Jacqueline was vulnerable: She had little contact with her family at that time, she worked but still struggled to make ends meet, and she was Latinx in a predominantly white community. I don’t know exactly how this combined to make love so difficult for her. Like many of my other patients, Jacqueline believed that she was just unlucky. Perhaps, but I find it far more likely that her vulnerability, not to mention her growing recognition that she did not belong in a man’s body, made her susceptible to falling for anyone that showed interest in her. Freud believed that we have a repetition compulsion, an inner drive to keep reaching out for the flame even though we know we’ll be burned. I don’t believe in anything that fatalistic, but I do think the past scratches its grooves upon us, and the record keeps skipping unless we move the needle.

Jacqueline’s first breakdowns began to occur around this point. Nearly every relationship ended with her either calling the police or having her now-ex-boyfriend drop her off at the emergency room doors. None of them accompanied her inside. She turned her pain inward, cutting herself to relieve the pressure that would build. Stress built upon stress, making her more vulnerable by the day. She began to see demons all around her. It was easier to believe that the world was infested by invisible evil rather than to confront the fact that it often shared a bed with her.

Jacqueline also began mental health treatment at that time. It’s easy to look at her fragile state when she entered my office and conclude that her prior therapists and psychiatrists didn’t do a very good job—and trust me, I’ve thought that too—but I don’t think that’s entirely fair. She achieved some level of stability in her previous clinic, and while I cringed when she told me some of the nakedly transphobic things her old therapist said to her, there were also things she really liked about her treatment there. It was close to her house, close enough that she could overcome her fear of public transportation to ride the bus a few stops to the clinic. She was also able to go there quickly if she was facing a psychiatric crisis, and often just talking to someone there for a few minutes would be enough to stabilize her. Given time, Jacqueline might have perceived the gaps in her treatment and looked for a better fit elsewhere, but she was not given that luxury. Her clinic was run by the city, and it happened to be one of the aforementioned locations quickly shuttered by Mayor Rahm Emanuel. That kicked off another spiral of hospital admissions and near-death experiences. Thankfully she survived. Many others did not.

There’s a name in hospitals for patients like Jacqueline who frequently make use of emergency services: “frequent fliers.” In some hospital record-keeping systems (not the one I work at, thankfully) their name is accompanied by a small airplane symbol to alert charge nurses and other emergency department staff if they haven’t met the patient at a prior visit. It is helpful to know that the patient sitting before you may be reporting symptoms of suicidality, stomach pain, or the like because it is freezing outside and they need a place to stay, but this can easily tip over into disrespect and disregard for the human being sitting in front of you. All too often it becomes another way to stigmatize those with serious mental illness.

I was hoping that my work with Jacqueline would help her quickly achieve stability so she could feel safe at home again. At our third session she told me that she wanted to be admitted to the hospital but wanted to wait until her mother got off work. I wasn’t entirely comfortable with this, but my supervisor gave me the go ahead. Fresh out of graduate school, I tried to engage her in a mindfulness exercise I had learned and thought would be helpful. We made it through two minutes before she begged me to stop. The demons she was hearing in her head were too loud. She had seen them leering at her in the waiting room, and they were now infiltrating her thoughts. She tried to resist them, but it became overwhelming.

Jacqueline did go to the hospital the next day. As I mentioned earlier, this became a pattern over the next year. Each time we concluded a session I checked her suicidality, but it seemed to vacillate wildly from day to day. I knew I couldn’t hospitalize her forever. Instead I began to work with her to find out what she liked so much about being there.

I have been on our hospital’s psychiatric floor several times to see my patients who are recovering there. It is a necessary place, of course, but also a deeply sad one. Our hospital building is very old, and to access the ward you must first walk along a narrow corridor with yellowed windows that open on the city skyline. There’s a faded shuffleboard court painted upon the tiles lining the walkway, a vestige from a different era. It looks like something out of One Flew Over the Cuckoo’s Nest. The rooms are small, airless. Each has a sink with a sheet of polished metal firmly latched to the wall to serve as a mirror, but age has dulled it to the point that you can barely make out your features. The television is on, loudly, in the common room. Someone is usually yelling. I always stop by the soda machine to treat myself before walking back to my office. It’s become my ritual, and not because I need the caffeine. The place is so depressing I need something to jolt me to my senses and provide a little mental distance before I resume my regular work.

That was what I saw, but that was not how Jacqueline experienced it. For her, it was a wonderful place to be. “I wish I could just live at the hospital,” she told me. She felt safe there. She enjoyed engaging with others in groups there even though she resisted attending groups in the outpatient clinic. She found the staff to be warm and affirming. She was never alone.

Jacqueline made great efforts to avoid feeling abandoned. She had a series of intense, short-lived relationships. She wasn’t quite sure who she was. She had made several attempts at suicide and frequently thought about it. She had difficulties controlling her anger. She often felt empty. Many professionals had looked at that list and diagnosed Jacqueline with borderline personality disorder (BPD). In one sense, they weren’t wrong; that list of the symptoms matches precisely with the DSM-5. BPD would be convenient in that it would capture her symptomatology, yet I never felt comfortable assigning her the diagnosis for a few key reasons.

Personality disorders are a strange beast. The DSM-5 defines a personality disorder as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” We don’t think of depression as being “pervasive and inflexible”; even more serious mental illnesses like schizophrenia are fairly capable of being managed. There is no drug, no cure for a personality disorder. It simply names who you are.

A diagnosis of borderline personality disorder comes loaded with even more baggage. I have heard colleagues usually dedicated to person-first language (e.g., “person with schizophrenia” rather than “schizophrenic”) refer to patients with the diagnosis as “borderlines.” A recent bestselling self-help book written by a psychiatrist described dating people with BPD as “addictively exciting, and it’s hard to say no to a girl who’ll jump your bones in a bathroom stall, or accept a dare to flash a cop, or drink you under the table. At least until she kills your dog … a borderline is many things, but she is most often known as the reason men think all women are nuts.”¹ A 2015 study² found that psychiatric nurses had less empathy for patients with borderline personality disorder than those with other mental illnesses, and psychiatrists were less likely to recommend hospitalization for suicidal ideation if a patient had borderline personality disorder. These negative attitudes actually increased the more one had professional contact with a person with BPD.

Borderline personality disorder is also a gendered diagnosis. The DSM-5 notes that 75 percent of those diagnosed with BPD are women even though the symptoms appear to be equally present regardless of gender.³ Childhood trauma is experienced by the majority of those diagnosed with BPD, and the more severe the trauma, the more pronounced the symptoms.⁴ The symptoms of BPD seem eerily similar to the antiquated notion of hysteria, so named because it was thought that it was caused by a shifting uterus. (Hysterika is Greek for “uterus.”) As hysteria faded into the background, BPD took its place. The diagnosis combined with the stigma often leads to women being punished for their response to abuse and assaults. It’s like inventing a diagnosis of acute gunshot disorder without investigating who fired the weapon.

Jacqueline’s identity as a transgender woman made the diagnosis of BPD even more punitive. It did not seem fair to Jacqueline or the rest of the transgender community to blame her for suffering the hatred and intolerance of the rest of society. As far as I could see, Jacqueline felt thrice rejected: by the culture at large for being Latinx, by her Latinx culture by being LGBTQ, and by the LGBTQ community by being a trans woman of color.

Not feeling safe in your neighborhood can be a function of mental illness, a response to the real threat of community violence, or both. I believed Jacqueline when she said that it wasn’t always safe for her to go outside dressed as a woman. According to the Human Rights Campaign, in 2017 at least 28 transgender people were murdered in the United States. (Many victims are misgendered in media and police reports, which suggests that the actual figure could be much higher.) Trans women of color are at an even greater risk of violence.⁵ Two trans women were killed in Chicago in the span of six months while I was treating Jacqueline. On September 11, 2016, the body of T.T. Saffore was found near railroad tracks in West Garfield Park. Tiara Richmond (also known as Keke Collier) was shot in Englewood on February 21, 2017.⁶ Jacqueline unfortunately had good reason to fear for her life every time she walked out her front door.

Chicago has several neighborhoods that are home to a significant LGBTQ population where Jacqueline might feel safer. Perhaps the most notable is Boystown, home to many of her favorite memories from the time right after she had come out.⁷ Chicago’s gay enclaves used to be located closer to the downtown area, but as rents increased in the late 1960s and early 1970s LGBTQ nightlife shifted north to occupy a stretch of Halsted Street. For years, Boystown was the epicenter of the annual Pride Parade and home to a variety of nonprofits that served the gay community, and in 1997 Mayor Richard M. Daley officially recognized Boystown as Chicago’s gay district, installing large rainbow-colored pillars throughout the area. Boystown has steadily gentrified as societal acceptance of gay people increased, and the neighborhood is now often criticized for being very white and catering almost exclusively to gay men.

Boystown was where Jacqueline first found herself as a gay male, and she often wished to return there to live. She knew that she risked judgment as a trans woman of color, but it still felt safe to her. Years of rising rents had priced her out of the neighborhood, though, and most of the other LGBTQ-friendly neighborhoods in Chicago are similarly out of her reach. Like many of my patients with serious mental illness, Jacqueline receives federal disability payments each month, which serves as her primary source of income.

“Disability” is somewhat of a misnomer; the same name is often used to refer to two different programs. When applying for benefits as a disabled person, the applicant has to apply to two separate programs, Social Security Disability (SSDI) and Supplemental Security Income (SSI). To qualify for SSDI, you must work a certain number of years before becoming disabled and a certain amount of those years have to have occurred in the recent past. The amount you receive is variable depending upon your work history. If lack of work experience makes you ineligible for SSDI, you may qualify for SSI. As many of my patients have been experiencing mental illness for many years, the vast majority receive SSI rather than SSDI.

The maximum amount you can get for SSI is determined by the Federal Benefit Rate (FBR), which is calculated annually. For 2019, the FBR is $771 for an individual and $1,157 for a couple. Some states kick in some extra money beyond the federal limit, but the amount is usually insignificant. Keep in mind that that figure represents the maximum you can receive; if you receive any other form of income (which includes someone providing you with food or housing), the amount you get is deducted from the FBR. There is also a limit on resources, meaning that you cannot have more than $2,000 as an individual or $3,000 as a couple at any time to continue to be eligible for benefits.

When you first apply for disability, you mail in all of your materials and wait several months for someone to examine them and decide whether or not you are eligible. Most people are rejected at this stage; out of all of the patients I’ve treated as they went through the process, only one of them was approved on their first try. If you are denied, you have about two months to appeal. If you appeal, your case will linger for another several months until someone else takes a look at your paperwork. If they also deem you ineligible, you can appeal one more time and ask for a trial. That’s assuming you make it that far; some give up and, according to a 2017 report from the Washington Post, 10,000 people died in fiscal year 2017 while waiting for a final decision.⁸ At the end of this process, beneficiaries are only eligible for a maximum of $9,252 per year for an individual, $13,884 for a married couple. To put this in context, the latter figure is only 23 percent of the median U.S. household income ($61,372 as of September 2018). Receiving SSI can be a lifeline for many of my patients, but it also guarantees that they will continue living below the poverty line and prevents them from saving even small amounts to try to better themselves.

The average rent for a studio apartment in the cheapest neighborhood in the city (which also means one of the most dangerous neighborhoods) is $612. Even if Jacqueline could find an apartment below that rate, she would have little money left over for even the bare essentials. She would like to begin the process to officially change her gender and legal name, but that also takes money. If forced to choose between food and electricity or correcting her identification, she will, like most people, choose the former rather than the latter. Chicago House, a LGBTQ non-profit formed in the wake of the AIDS crisis, has developed a program to aid the at-risk trans population, and many of them are in the same boat as Jacqueline. Only 21 percent have been able to update all of their identification to conform to their correct name and gender identity. Transgender people experience homelessness at twice the rate of the general population. Most trans individuals experiencing homelessness at the very least experience harassment; 29 percent are turned away from homeless shelters and 22 percent are sexually assaulted there if they manage to get in.⁹

Contemporary society often pushes those who do not fit into its conventional boundaries into false selves, a concept first explored by British pediatrician Donald Winnicott in his 1960 book The Maturational Process and the Facilitating Environment. Inspired by Freud’s The Interpretation of Dreams, Winnicott was the first pediatrician in the United Kingdom to complete psychoanalytic training. He became involved with the effort to evacuate children from major cities to the countryside in the midst of World War II. Winnicott was struck by how devastating the move could be on young children, and for most of the rest of his career he was interested in how the infant develops into a child and eventually an adult. He attached profound significance to the early events of one’s life; even if one was no longer consciously aware of them, he believed that they continued to exert influence over the way one relates to others and forms relationships well into adulthood.

The pressure families and societies exert to ensure conformity at an early age has a similar effect on the psyche. One may be pushed to speak and write in a language that is not one’s own, be pressured to regard cultural practices and traditions as ‘odd’ or ‘un-American,” be forced to sublimate essential elements of one’s personality to fit in. As Winnicott notes, we all do this to some degree; the language that I use with my patients is not the language I use with my friends or my wife. I’m aware of this disparity, though, and can switch easily between personalities with opprobrium. Many others like Jacqueline don’t have it so easy.

Jacqueline was the first patient who made me think about Winnicott’s true and false selves. She took to describing her symptoms as the battle between “Jason”—her old masculine self who was angry, prone to self-harm, and desperately unhappy—and “Jacqueline”—her true feminine identity who was kind, happy, and loving. Right now she saw herself as in-between, an identity she called “Jackie.” Her internal mood would shift between the personalities depending upon how she was feeling at any given time. Jacqueline wanted to make it clear that she did not think she actually had multiple personalities, and indeed she demonstrated no signs of dissociative identity disorder (what used to be called multiple personality disorder). Rather, she felt pressure to be a false version of herself, and it took work to resist that pressure.

One of Jacqueline’s first false selves was a straight teenager. She had even gotten a past girlfriend pregnant when they were in high school, and although she did not regret the abortion that followed, she felt some regret that she had never become a parent. She then shifted into a gay male false self, slightly more comfortable but ultimately unsatisfying. It wasn’t until she finally became a transgender woman that she could begin to feel like herself, but this was not nearly as easy as it may sound.

Jacqueline heard voices inside her head, and they were cruel. They told her that she was not really a woman but a man, that God hated her, that she was disgusting. On one level these are psychotic symptoms, a manifestation of her mental illness. At the same time, they were also an internalization of the pressures to maintain her false self. Her illness may have provided the form of her psychosis, but culture provided its contents.

To be clear, several communities and institutions have let Jacqueline down, but if she had had access to good, affirming, and consistent mental health care, things could have been very different. Instead of receiving such services, her reliance upon the social safety net often forced her to migrate from clinic to clinic. Instead of a comprehensive diagnosis that would take stock of the variety of societal pressures that helped create her suffering, she was affixed with a label that blamed it all on her. Instead of being treated humanely, she was written off as just another dramatic and manipulative borderline.

Jacqueline’s discomfort with her true self meant that she found it very hard to be alone. She had lived by herself earlier in her twenties, but when her symptoms worsened she moved back in with her mother. Due to her frequent suicide attempts, she was on virtual lockdown inside her home. Her mother removed the doors from her bedroom and the bathroom. She had to ask her mother for a knife to cut her food or a razor to shave. I could sympathize with her mother’s caution to a degree. Jacqueline could be quite impulsive, and I also feared what she could do with little forethought. At the same time, however, that’s not much of a way to live.