InvisALERT Solutions – ObservSMART

Through a Glass Darkly: Poverty and Mental Health in The Bronx

Each day I take a journey to the northern tip of our city, to the Northeast Bronx, where I am the director of an outpatient mental health clinic. I am a visitor from another country, Manhattan, and I inhabit this world and see it through the eyes of a white, middle-class outsider. As the 5 train snakes along the track above ground at East 180th Street, I can see the last hint of the spires of Manhattan. The Empire State Building, sharp and shining, points upward, a beacon of wealth, seemingly a million miles away. On the way to my office, walking down Astor Avenue off of Boston Road, I pass the field of dead umbrellas, broken birds. It is more an empty lot, actually, with capless soda bottles and ragged wrappers strewn alongside the metal spokes. In one block we have our Dominican bodega, the American-Albanian bakery, China Kitchen and Irving Freireich, the accountant. He may be the last Jew in the neighborhood where all our Jewish grandparents grew up. Next door to him a storefront houses two-foot figurines of Madonnas, Kings, and Saints lined up to watch the spectacle that passes daily. They’ve seen fistfights and fake fights and the “Albanian Boys Incorporated” threaten the Black and Latino kids who previously owned our corner. One day I looked out my office window and saw an old-fashioned rumble, shirtless Albanian teens with bats and chains, challenging the kids of color who make up the majority in this neighborhood. There are some Bloods and some Crips and some gang wanna-be’s.

It’s the wanna-be’s who make it further down the street to our door. And their parents, who are nurse’s assistants, bus drivers and cashiers, as well as housing project managers and food service personnel, some teachers, waitresses and cops. And many who can’t find work or are emotionally unable to work, who struggle to get by on Disability or Public Assistance. They pray they can keep their Medicaid, and thank God daily for Child Health Plus, the state government program. This is an overwhelmingly poor neighborhood, with many working low-wage and minimum-wage jobs and many more who don’t work at all.

It’s Spring in one of the nation’s poorest counties, and the yellow forsythia is the only spot of color near streets littered with dog poop, where the churning wheels of the El make harsh atonal music amidst the groaning of sirens and the urgent horn blaring of fire trucks. There is no silence here. The poverty is evident in the grayness of the faces, the canes and walkers and wheelchairs, the expanding thighs and hips of the many eating McDonald’s on the run, sipping huge Cokes. The Albanians around us are a closed and quiet people. The men have no work. They sit in groups in an all-male bar where they smoke and peer cautiously out at this American land of no opportunity. The older generation meets around the cement chess table on Pelham Parkway, with tattered jackets and wizened faces. Women looking twenty years older than their age occupy themselves with the children. “There’s no Hope in Dope” is the sign on the wall of the Albanian bakery, next to a carving of “Nene Tereza 1910-1997,” their Sister of Mercy.

The Bronx is the borough New York left behind. Local physicians report that the patients in the Bronx are the unhealthiest they have ever treated. There is an increase in Type 2 diabetes, and children make up half of the diabetes cases. Bronx County has the third highest rate of asthma in the entire state. As a result of the link between obesity, air pollution and asthma, Bronx MDs see a “systemic inflammation” and breathing gets more and more laborious for these Bronx residents. The official unemployment rate in the North Bronx is about 14 percent and in the South Bronx nearly 20 percent, compared to the national rate of 10 percent (From “Health of the Bronx: Have We Created the Perfect Storm?” Lower Hudson/Bronx MDNews, April 2010, available at: The actual unemployment rate may be twice those already appalling numbers, if you take into account people working only part time and “discouraged workers.”

The rooftops are covered in graffiti the way the 9th Ward was after Hurricane Katrina, SOSs in spray paint. The boys’ pants are not only below their hips, they’re belted below their butts. Rows of boys with boxers billowing strut down the street from Columbus High School to reach the Dominican bodega next door. “F*** this and Mother f*** that”; the girls are shrill in their condemnation of every imaginable thing as they saunter by the clinic in tight pants and painted nails, some with sparkles or stars. At three PM there are bursts of electricity as they light up our street with excitement: they’re finally leaving school, where not much seems to go in and very little seems to come out. The neighborhood is alive in a dying community where the Verizon store is the only sign of the 21st century.

I am the white ghost on the train, weaving in and around my 9 to 5 neighbors, invisible but trying to leave an imprint. We come to make a difference, but my question is: Are we able to help them help themselves? They didn’t make the rules, after all; we did.

We are an outpatient mental health clinic in the Northeast Bronx run by JBFCS, a city-wide social service agency that is largely government funded and also supported by the UJA and other philanthropic donors. At my clinic we have 750 outpatients at any given time; about half are kids. Our referrals are from neighboring schools, hospitals, and physicians treating patients who suffer not only from obesity, asthma and diabetes, but also depression, anxiety and post-traumatic stress disorder. It’s a community without community centers. An overwhelmed school district with underperforming schools armed with metal detectors. No PTAs, and one guidance counselor for hundreds of kids. The children come to us via the psychiatric emergency room, sent there by teachers and principals who fear the thrown chair, the cursing mouth, the threat to shoot somebody dead or jump out of a window.

We are the DMZ for this part of the Bronx; we offer neutrality, sunlit offices and a bright and comfortable waiting room with colorful posters by Black and Latino artists, carpets, books and plants. Members of our Board donate books for our waiting room, as do New York City publishing companies I seek out. Our patients read, gobbling up books and magazines hungrily. They read everything, from Brides’ Magazine to The Nation, The New Yorker and Yachting. The classics, autobiographies, Golf Digest and The Little Engine That Could.

One third of our staff members are people of color, with their own varied backgrounds: from the Caribbean, via England; from Puerto Rico and the Dominican Republic. We also have an Iranian American, two Iraqi Jews, and Asian and Russian support staff. We run biweekly Diversity Seminars for clinical and support staff, trying to deal with issues of race and racism that emerge amongst staff or with clients. This, in turn, assists the therapists in their goal of genuine interaction with the people who come to us for help. Our clients are overwhelmingly people of color, making those of us who are white especially stand out.

The problems our clients bring us, however, cross all color and class lines, and the pain they suffer is magnified by the economic and racial disparities and indignities they experience in the world around them. The rage or depression they live with can explode at a moment’s notice, and the expression of it can go from zero to a hundred in a split second. There is no slow burn, no long fuse. A breakup, a verbal taunt, a slap in the face, can provoke self-inflicted cuts on the inside of the wrist, taking a whole bottle of Tylenol, or wielding a knife in self-defense. Or all three responses. Most of our women clients were sexually abused as children, and they are haunted by trauma. Many of the children have witnessed their parents hit each other. Some have been taken away from their homes and sent to foster care, because one or both parents have forgotten to take them to school or are using a drug of choice. Or because their own untreated traumatic histories have wounded them so deeply they can’t find the resources to parent, especially without the help of extended families. But these clients are not statistics to us. Each one has a history, a new story, a family tree, a newborn baby and dreams they aspire to. We see them every week, and listen to each detail the clients provide, to every effort they make to provide a good life for their children, and to every obstacle they encounter along the way. As much as we are able, we try to clear the road ahead of obstacles (the ones we have some control over) and open our clients to the possibility of hope.

Some of Our Patients and Their Stories

With one small child at home and seven months pregnant with her second, Josie tried to kill herself at 22 by jumping onto the subway tracks as the train approached. She had just discovered that the father of her unborn baby had conceived another baby at the same time, and that woman called her to brag that she would give birth in two months as well. Josie lost her leg up to the knee and part of her hand, but she survived, as did the baby. She came to her first session in a wheelchair with her mother, and she was not happy about being alive.

Maria had twin teenage sons and a younger son. One of her twin sons was found hanging in the shower after he was kicked out of school for a minor infringement of the rules. The family was referred to us one week after the suicide and the mother was paralyzed with grief and guilt. The remaining boys were ashamed to go to school and could not articulate their feelings. The boys are finally coming up for air, having lived with the empty bed at home every single day. Two years after they first came, their mother gave birth to a baby girl. The mother’s therapist gave her a baby shower with the members of Maria’s therapy group at the clinic, with pink decorations on the office walls.

Elena was bathing the baby when she received a phone call in the living room. In an instant of poor judgment, she ran out to answer the phone and when she returned, the baby had drowned. She came to us when the authorities refused to let her keep her second child. As she mourned for her first, she grieved for the loss of her second. After a year in therapy, the authorities reunited her permanently with her second child.

Latasha is bipolar, as are her two teenage daughters. The elder daughter stabbed her father. The family was separated as the father had to leave the home. The family then moved from shelter to shelter and all three stopped taking their medications. Latasha was unable to function and risked psychiatric hospitalization; she had been many times. Once re-stabilized on her medicines, Latasha managed to hold her family together. Patrice, a victim of years of domestic violence at the hands of her husband, was unable to work as the result of an unmedicated case of bipolar disorder. Her estranged husband kept her on his health insurance, so she was unable to get Medicaid and he refused to pay her co-pays or cover any medical expenses. Off medication, Patrice often felt unable to care for her young teenage sons and asked her ex- to keep them for a few extra days. Instead he dropped them off at her home when she was feeling acutely depressed. She went to the emergency room for medication and while there, social workers observed bruises on the boys; the boys indicated that their father had hit them. Patrice felt so overwhelmed she stated she couldn’t take them home and they were sent to a foster home. There are times when she cannot afford food or household supplies, often has no money for tampons or toilet paper. She had no winter coat. The older boy began writing about death on his Facebook page, and soon after had carved a broken heart on the inside of his arm.

Our patients’ lives are so difficult not only because of their personal histories, but because of the poverty they live in, the racism they encounter, the language barrier faced by our Latino population, and the lack of steady work or affordable health insurance. As a result of these disparities, they have lived in constant crisis, and have experienced a series of complex traumas. In these times of economic stress, we see an increase in domestic violence and substance abuse, and consequently, a higher frequency of suicidal thinking in children. Every week there are a handful of child and adolescent patients taken to the Psychiatric Emergency Room for an assessment of suicidal intent. About half are hospitalized.

Tiana was 13 when she attended a “hooky party”, where she consumed a lot of alcohol and willingly had sex with a boy she didn’t know. Later on at the party she was raped by another boy. Her mother called the police, who are conducting an investigation. Tiana had a history of self-cutting. Since the rape she has had to have multiple examinations for STDs and is taking HIV medications prophylactically.

A 15-year old Latino boy accepted that he was gay, but his mother could not and continued to shame him with insults and subtle slights. He ran away from home for a week and stated he just “hung out at Barnes and Nobles in the city” until closing. After he returned home, it was never clear where he had really been or what he had been doing. A lot of gay kids of color in the Bronx are in the closet, in spite of efforts to provide them extra support.

In session, eight-year old Darnell admitted his father hits him on the head with the wooden pole of the broomstick, with wet shoes and a belt. He said he really tries to be a good boy. We reported it to the State Central Registry in Albany. The parents continue to come to us for marriage counseling and psychoeducation on ways to set limits with their children without resorting to violence.

Sixteen-year old Thomas told his therapist that he had fantasies of hurting some of the kids in his high school. He had been fascinated by the murderous events at Columbine and Virginia Tech and was reading articles about them online. A psychiatric evaluation revealed that Thomas had very low self-esteem and was constantly comparing himself to his very successful younger brother. We continue to monitor him very closely, and his fantasies have lessened.

Edwin, 13, had been in treatment at our clinic for over a year, for sexualized behavior towards girls in school and one psychiatric hospitalization for suicidal thinking. Over one summer weekend, we learned that his father had allegedly strangled Edwin’s pregnant, 16-year-old sister and tried to hide the nude body in the furnace of his building. Edwin’s mother’s world crashed around her, since she had let the kids visit her ex-husband knowing his past history of violence towards her. The family was destroyed as Edwin’s father went to jail and his sister was dead. Later we learned that the father was responsible for the sister’s pregnancy.

So many questions arise when working in this parallel universe. How is it that so many African American and Latino boys aged 6 to 13 have “Attention Deficit Disorder”? Is it because they no longer have recess at school, so the boys are literally bouncing off the walls or because a label and medication are easier to dispense than a response to the larger crises they live through? If kids have been physically or sexually abused, how can they sit still and learn geometry? What happened to school personnel handling things that happen in school? Now 911 is the first response and children no taller than a sapling are transported in ambulances to a psychiatric emergency room in a hospital for a mental health evaluation. There they are prematurely saddled with a label, a diagnosis and a stigma. When parents stop bringing their depressed or suicidal children to us for therapy, we have to call ACS and we lose our role as neutral parties. We scout out neglect like squirrels foraging for nuts. Since the majority of our clients are people of color, and many on staff are white, the racial hierarchy is even more pronounced. We are the strictest mothers and fathers; we follow rules and respect limits. We also acknowledge the strength they show in the face of terrible odds: they start at a disadvantage and never quite catch up.

There is an advantage to being a white, middle class ghost in the Bronx. As in most situations when one is white, I have the choice to come or to leave when I want to. But I am always deeply affected by the stories I hear day after day. I am never inured to the heartbreaking tales of human betrayal, as male family members and strangers alike steal the innocence from their young girls, leaving them fearful of going to the dentist where their mouths feel exploited once again; untrusting in relationships with men who may have no wish to hurt them when they grow up; or passing on fear and twisted notions of sexual development to their daughters. My staff, who hear the stories in great detail week after week, do tend to get numb, and my job is to try to prevent the vicarious traumatization to which they are vulnerable. They have to have a place to debrief, to cry if they need to, to take a long, steady exhale between the stories of grievous loss and destruction of the spirit. It is these close encounters with the cruelty of human nature that can dehumanize us, and we have to keep fighting to believe that there is goodness left in resilience and in the struggle itself. Sometimes it just takes your breath away; all of it.

Julie List, LCSW, is a licensed clinical social worker, psychotherapist and the Director of the Harry Blumenfeld Pelham Counseling Center of JBFCS.

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