experiencing homelessness who also had a serious mental illness. Case management gives you a crash course in the inadequacies of our social safety net, but aside from filling out paperwork and making calls I also got to learn about my clients’ lives over cups of bad fast food coffee. I quickly figured out that this is what I enjoyed the most. These experiences led me to become a therapist. The clinic where I work is the outpatient psychiatric department of a safety net hospital on the West Side of Chicago. After Jacqueline was admitted, I went back across the street to the clinic and saw six other patients the same day, all with varying levels of need.
The movement to create clinics like the one where I work began in 1963 when President Kennedy signed the Community Mental Health Act. This act delegated federal funds to build community mental health centers across the country, a notable shift away from the institutional model of years prior. Kennedy’s sister Rosemary underwent a forced lobotomy in 1941 that left her with the intellectual capacity of a two-year-old. I like to think that Kennedy had this in mind when he offered an alternative, humane way to treat those with mental illness.
The actual law was rather toothless and didn’t lead to many notable outcomes, but it played a key symbolic role in the deinstitutionalization movement in the United States. Psychopharmacology had begun to advance beyond what was largely a guessing game into something that resembled a science. Fourteen antipsychotic medications were developed in the United States between 1954 and 1975.1 The first two antidepressants, iproniazid and imipramine, were introduced in the 1950s.2 These drugs were far from perfect; the earliest antipsychotics could induce irreversible Parkinsonian-like tremors and cause patients to have a need to be in constant motion (known as akathisia). Iproniazid was later found to cause liver damage and removed from the market. Nevertheless, deinstitutionalization proceeded rapidly, and while the movement should rightly be criticized for sending many patients from a bed and into homelessness, the asylums which went out of business were awful places much prone to abuse that did little to ease the suffering of those confined there.
As persons with serious mental illness were increasingly encouraged to live in their communities, the need for robust outpatient mental health services based in the community increased. Unfortunately, the growth and availability of such services did not proceed nearly as rapidly as the pace of deinstitutionalization, and the gaps in care continue to the present day. For those states with the poorest options for mental health care, providers (social workers like myself, counselors, psychiatrists, psychologists, and psychiatric nurse practitioners) would have to treat six times as many patients as those in well-funded states. Of course this is impossible, so instead people are forced to do without.
In Alabama, for instance, there is one mental health professional per 1,260 residents.3 Alabama doesn’t even rank last in terms of the percentage of the state budget allocated to mental health services; at 1.5 percent, they’re ranked thirty-fifth in the nation. Arkansas is last with just 0.7 percent. Mental health services are rarely a priority and were particularly hit by cuts made in the wake of the 2008 recession; states slashed at least $4.35 billion from their mental health budgets between 2009 and 2012.4 The most recent statistics from the Bureau of Health Workforce tracking Health Professional Shortage Areas that lack adequate healthcare estimated that 110 million Americans, roughly a third of the country (but concentrated in urban and rural areas), lack access to a psychiatrist.5
In this book I will focus on Chicago because it’s what I know best, but there is no state, no city in America that does an adequate job taking care of its citizens with mental illness. Access to mental health services in Chicago, like so many other things, depends upon your ZIP code. If you live in one of the richest neighborhoods, such as the Gold Coast, there are 4.41 mental health professionals per 1,000 residents. Travel to the Southwest Side where I work and that figure drops to 0.17.6 But it hasn’t always been like this. In the 1960s and 1970s the city had nineteen community mental health centers spread across the city. Various mayoral administrations chipped away at this until the city was left with twelve. Then came Rahm Emanuel.
Emanuel was sworn in as mayor on May 16, 2011, and within a year he had closed six of the remaining clinics. The stated rationale was to reduce costs as part of a larger effort to trim the budget. The overall savings according to the city’s own figures was estimated to be about $3 million, equaling 0.04 percent of overall expenditures that year. By that point the clinics mostly existed to serve city residents without insurance, and the majority of their patients were Black and Latinx. Emanuel and his staff promised that the 3,000 or so patients of the shuttered clinics would be able to receive services elsewhere, seemingly not accounting for the fact that mental health services in Chicago were already far from adequate. In 2016, the city privatized one of the remaining clinics, leaving Chicago with just five community mental health centers for 2.7 million people.
But Emanuel was not done. Just one year later, he closed fifty schools throughout the city, once again in primarily black and brown neighborhoods. This time, the excuse was to improve outcomes by consolidating services and eliminating poor performing schools with declining attendance. Chicago Public Schools also hoped to save money through the closings, although to date they have not shared statistics on whether or not they were successful. A 2018 study by the University of Chicago Consortium on School Research examined the primary rationale for the closings—academic test scores—and found that students from schools that were closed actually had lower test scores in their new schools, particularly in math. In addition to these quantitative statistics, the students also reported that the process felt rushed to them, left them in mourning for their communities and their schools, and created “us versus them” dynamics in their receiving schools.7
Alongside this reduction in access to needed social services and supports, Chicago’s annual murder rate began to spike. In 2012, Emanuel’s first full year in office, the total number of murders in Chicago was 436. The number hovered around 400 until 2016 when the city experienced a massive spike in violence, resulting in 771 murders. The number declined the next year, but only slightly; 650 people were murdered in 2017. Armchair experts of all stripes are quick to suggest reasons for the rapid increase, often in barely-coded racialized language, but no one has been able to identify a single trigger for the rise in violence.8
Closing mental health clinics, closing schools, rising rates of violence: each usually gets treated as its own story, but residents of Chicago’s South and West Sides are not allowed that luxury. Chicago’s murder rate did not rise in a vacuum; while it’s impossible to draw causal lines from the mental health clinic or school closings to the homicide rate, it’s hardly a radical thought to suggest that eliminating crucial mental health services while causing patients and schoolchildren to cross gang and community lines in order to see their therapist or simply go to school has not further endangered the lives of the city’s poorest residents. We rarely talk about these issues at all, and conversations that focus upon the actual lives impacted are rarer still. This book aims to spark such a discussion.
Chicago was and is a city that is deeply segregated by race. It is a common stereotype to depict the minority urban dwellers as those who are forgotten by those in power. I no longer find this depiction to be true. Rather, their lives are under constant surveillance from multiple systems and institutions. Thanks to Michelle Alexander’s The New Jim Crow, more people are aware of the evil that is mass incarceration. The fact that 2.3 million Americans, a disproportionate number of whom are Black and Latinx, are currently imprisoned is a national shame. However, there are more than twice that number of citizens who are on parole or probation, creating a system of mass supervision that continues to control their lives long after they have supposedly paid their dues to society.9
The intrusion of the state on minority lives is not limited to the police or the criminal justice system, however. We often talk about “the system” or “the government” as being some singular, monolithic entity. This language only heightens its power by making it seem both inevitable and incapable
