Community Policy, Community Health

Jonathan Foiles’s book highlights the role of policy and social context in mental illness through Chicago case studies

I first started writing this review of This City Is Killing Me: Community Trauma and Toxic Stress in Urban America prior to the current global pandemic. While nothing about the book changed, the starkness of its perspective—looking at issues of housing segregation, poverty, racism, and gendered violence as part of the larger landscape contributing to individuals’ experience with mental illness—seems particularly critical. COVID-19 operates as the deadliest killer of vulnerable persons like those discussed in This City Is Killing Me because of that same larger landscape, and the mental health effects of living under its shadow are likely to do the same. 

The book is a series of five case studies or narratives about therapeutic work done in collaboration between its author Jonathan Foiles, then a clinical social worker at Mt. Sinai Hospital in North Lawndale, and his clients. The narratives are presented as lengthier vignettes that are specific about policy and clinical details but accessible to lay people. Each person’s story simultaneously speaks to that person’s life struggles (the book’s subtitle is, after all, “community trauma and toxic stress in urban America”) and the social-historical context that makes the story seem almost inevitable. In an interview with the Weekly, Foiles said, “My writing bums people out. We should be bummed out.” Instead of succumbing to the pain of trauma and stress, Foiles encourages us to “confront the impact policy decisions have upon the city’s poorest residents.”

Through Jacqueline, a patient diagnosed with borderline personality disorder, readers explore the intersection of mental illness and urbanization in the context of gentrification, safe spaces, and the closing of Chicago and Cook County’s public mental health clinics. In the mental health field, a diagnosis of borderline personality disorder expresses someone’s experience of extreme instability in all relationships even with themselves. The stigma of this diagnosis places a person at risk of being dismissed and judged harshly by peers and professionals. In the book, you are drawn (briefly) into Jacqueline’s family experience, her own struggles with gender identity, her eventual “pricing out” of the Boystown neighborhood where she once found some refuge, and her difficulty with a fixed income that doesn’t allow even the medical system in her life to be stable. The most consistent service Jacqueline received was publicly funded healthcare near her home. But when six of the city’s then-twelve public mental health clinics were closed in 2012, accessibility and continuity of care became simultaneously more challenging almost overnight. I would like to think that if someone reads this type of story, they can make a leap to appreciate that a context that feels unstable can work as both a catalyst and a continued reinforcement of an individual’s pattern of instability. 

Frida reminds us of the burden we place on parenting and the limited resources our child welfare system has to actually assist people in being the best caregiver they can. When we are introduced to Frida, she’s involved in services required by the state Department of Children and Family Services (DCFS) to be reunited with her children (after one walked outside with no coat in a snowstorm), and is a few months past suicidal behavior that occurred while she was dealing with grief after her father’s death and her separation from her children. Frida’s story includes a look at her ability to parent, and also who she is and how she reached her current struggles: her relationship with her father, who looked the other way when she was abused as a child and who may have suffered from mental illness; her relationship with heroin (she relapses into use); and her relationship with her children. DCFS, Foiles points out, was not as interested in dealing with Frida as a whole person—or even in giving her tools to succeed—as he was as a therapist. As her overloaded caseworkers kept leaving the agency, the state budget impasse at the time slowed down her access to required services, and Frida continued to face additional struggles in the rest of her life, her resolve was worn down. She eventually signed over her parental rights to a relative.

Frida’s story speaks to me as a parent; I can see myself in her. No parent is perfect, and yet my mistakes as a parent 1) may not show up until much further down the developmental path and 2) are not currently considered “errors” for which the penalty is involvement in the child welfare system. In my mind, it is clear that this is all that separates me—and many other Black parents—from the same fate. And if I represent a relatively healthy parent raising relatively healthy children, how much more challenging is it to not make a “mistake” if you carry the burdens of personal trauma and limited financial resources, and are expected to work within a system of interventions that, according to Foiles, “do little to help families learn how to better parent and have limited impact on the recidivism rate,” and instead attempts to socially control the movements of poor and predominantly Black and brown families?

The three men in the book experience delusional beliefs and homelessness, inflated sense of self and the salvation and damnation of CPS schools and trauma, and grief and loss through violence. I see them in other people I’ve known and seen, although not as much in my own identity. I am left wondering about their impact on others as men, who despite their woes carry a certain amount of power in relationships not experienced by Jacqueline or Frida. Robert, a former Cabrini-Green resident who is homeless when we meet him, demonstrates how it might be safer and more rational to live in a world of your own making. Luis protects himself with mood changes and beliefs in his masculinity from facing the belief that his family and schools failed him. Anthony reminds us of the crushing grief and loss of a child in a society that labels children such as his as anything but childlike, and gives us the gritty reminder of the work still needed in criminal justice reform. 

The book is not for light reading if you heed its call for engagement in policy issues around providing mental health clinics and insurance and addressing community violence, two issues which come up in Foiles’s work with patients. Foiles explained to me that one of the first things he wrote for public engagement was a piece on the Affordable Care Act for Slate, and then he continued to write about policy and mental health until reaching this book. He discussed how therapists (and also frontline social service workers, as well as medical professionals) are seeing the “human impact” of policy when they see their clients. While Foiles acknowledges policymakers are not often “listening” to these stories, he believes more clinicians should “speak up.” 

The problem with diagnosing mental illness is that, despite clinician intentions to the contrary, it is often treated as a biological and/or moral failure of the individual. We are in fact an un-empathic nation, built on a belief system of rugged individualism and exceptionalism. One way society displays this lack of empathy is encoded in policy decisions related to the social safety net—think aid and assistance for those in poverty or otherwise in need, services for older adults, and services for immigrants as prime examples. The belief in rugged individualism allows people to uncouple individual issues, here mental illness, from social context. Belief in exceptionalism allows us to retain the concept of rising “above” problematic circumstances to achieve our dreams and goals.Therefore not only does mental illness become a failure of the individual, society then treats anything that is “different” or against normality as the natural outcome (and therefore undeserving of investment in remedies) for nonconformity to scripted, acceptable social roles. What This City Is Killing Me does is bring the issues of society and institutions into sharper focus by making plain the inextricable link between policy decisions and the mental health and well-being of people who live and die by these choices.

Jonathan Foiles, This City Is Killing Me: Community Trauma and Toxic Stress in Urban America. $16.95. Belt Publishing. 130 pages

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Michelle Anderson is an education editor at the Weekly. This is her first piece for the Weekly.

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