The Noonday Demon (63 page)

“There’s one room in the new place for the boys and one for the girls and one for me, but they all just like to get up on my bed with me and we’re all sitting around there at night. That’s all I need now, is my kids. I never thought I would get this far. It feels good to be happy. I don’t know how long it’s gonna last, but I sure hope it’s forever. And things keep on changing: the way I dress. The way I look. The way I act. The way I feel. I’m not afraid anymore. I can walk out the door not being afraid. I don’t think those bad feelings are coming back.” Lolly smiled and then shook her head in wonder. “And if it weren’t for Dr. Miranda and that, I’d still be at home in bed, if I was still alive at all.”

The treatments Lolly received did not include psychopharmaceutical intervention and were not closely based on cognitive models. What was it that enabled this metamorphosis? In part, it was simply the steady glow of affectionate attention from the doctors with whom she worked. As Phaly Nuon in Cambodia observed, love and trust can be great justifiers,
and the knowledge that someone else cares what happens to you is by itself sufficient to affect profoundly what you do. I was struck by Lolly’s statement that the naming of her complaint as
depression
had brought her relief. Miranda described Lolly as “clearly” having depression, but this had not been clear to Lolly even when she had suffered extreme symptoms. The labeling of her complaint was an essential step toward her recovery from it. What can be named and described can be contained: the word
depression
separated Lolly’s illness from her personality. If all the things she disliked in herself could be grouped together as aspects of a disease, that left her good qualities as the “real” Lolly, and it was much easier for her to like this real Lolly, and to turn this real Lolly against the problems that afflicted her. To be given the idea of depression is to master a socially powerful linguistic tool that segregates and empowers the better self to which suffering people aspire. Though the problem of articulation is a universal, it is particularly acute for the indigent, who are starved for this vocabulary—which is why basic tools such as group therapy can be so utterly transforming for them.

Because the poor have limited access to the language of mental illness, their depression is not usually manifest cognitively. They are unlikely to experience intense guilt and to articulate to themselves the perception of personal failure that plays so large a role in middle-class depression. Their complaint is often evident in physical symptoms: sleeplessness and exhaustion, sickness, terror, an inability to relate to others. These in turn make them vulnerable to physical illness; and being ill is often the straw that breaks a camel’s wide back and makes someone with mild depression go over the edge. Insofar as the indigent depressed do get to hospitals, they tend to get there for physical ailments, many of which are symptoms of their mental anguish. “If a poor Latin woman seems depressed,” says Juan López of the University of Michigan, who has done extensive mental health work among poor, depressed Spanish-speaking populations, “I try her on antidepressants. We talk about them as tonics for her general complaints, and when they work, she is delighted. She herself does not experience her condition as psychological.” Lolly too was experiencing her symptoms outside the realm of what she would have perceived to be craziness, and craziness (acute hallucinatory psychosis) was her only model for mental illness. The idea of a debilitating mental illness that was not rendering her incoherent was outside her lexicon.

Ruth Ann Janesson was born in a trailer in rural Virginia and grew up fat with glasses. At seventeen, she got pregnant by a nearly illiterate man who had dropped out of her school, and she cut off her own education to
marry him. They had a disastrous marriage; she worked and made ends meet for a while, but after the birth of their second child, she left him. A few years later she married a laborer who operates machinery in a construction yard. She had managed to get a truck-driving license, but within six months her husband had told her that her place was at home taking care of the family and taking care of him. They had had two children. Ruth Ann was trying to make ends meet, “which is hard for a family of six on two hundred dollars a week, even with the food stamps.”

She soon began to drift downward, and by the third year of her second marriage she was losing all signs of vitality. “I had just decided, well, I’m here, I’m existing, and that’s it. I was married, I had children, but I had no life and I was feeling bad basically all the time.” When Ruth Ann’s father died, she “lost it completely,” she said. “That was the bottom. My daddy never beat us, it wasn’t the physical, it was the mental. Even if you’d done good, you never got praise, but you were criticized all the time. I guess I felt that if I couldn’t please him, I couldn’t do anything else. And I felt I’d never managed to please him well enough, and now I wasn’t ever gonna have the chance.” Recounting this period of her life to me, Ruth Ann began to cry, and by the time she finished her story, she had used up an entire box of Kleenex.

Ruth Ann went to bed and mostly stayed there. “I knew something was wrong, but I didn’t put a medical term to it. I had no energy whatsoever. I began gaining more and more weight. I was going through the motions inside our trailer, but I never went out and I stopped communicating totally. Then I realized that I was neglecting my own children. Something had to be done.” Ruth Ann has Crohn’s disease, and even though she was doing barely anything, she began to get what appeared to be stress-related symptoms. Her doctor, who knew about Emily Hauenstein’s study, recommended her for it. Ruth Ann began taking Paxil and started seeing Marian Kyner, a therapist who worked full-time with the women in Emily Hauenstein’s study. “If it wasn’t for Marian, I probably would’ve just stayed sitting in that same hole I was in until I just stopped living, stopped existing. If it wasn’t for her, I wouldn’t be here today,” Ruth Ann told me, and once more burst into tears. “Marian made me reach inside me, she wanted me to get all the way down to my toes. I found out who I am. I didn’t like it, didn’t like me.”

Ruth Ann calmed herself. “And then the changes began,” she said to me. “They tell me I have a big heart. I didn’t think I had a heart at all, but now I know that it’s there somewhere and eventually I’m gonna find it completely.” Ruth Ann started working again, as a part-time temp for At Work Personnel Service. She soon became office manager and at that point phased out her antidepressants. In January 1998, she and a
friend bought out the business, which is a franchise under license from a national company. Ruth Ann began taking night courses in accounting so that she could keep the books well, and she soon recorded an ad for cable TV. “We work with the unemployment office,” she told me, “getting jobs for people who are out of work, placing them in private industry. We train them in our own office, where they help us, and then we send them out with good skills. We’re now covering seventeen counties.” At her heaviest, she weighed 210 pounds. Now she goes to a gym regularly and with intensive dieting is down to 135.

She left her husband, who wanted her to be in the kitchen waiting for him, depressed or not, but she is giving him time to adjust to her new self and when I last saw her was still hoping for a reconciliation. She glowed. “Sometimes a new feeling will hit me,” she said, “and it scares me. It takes me a few days to figure out what it is. But at least I know now that my feelings are there, that they exist.” Ruth Ann had a profoundly new relationship with her children. “I help them with schoolwork at night, and my oldest son decided computers were awesome, and now he’s teaching me how to use them. That’s really helped his confidence. We’ve got him working in the firm this summer, and he’s great. It’s not so long ago that he was complaining of being tired, that he was missing school most days. Until now, the only thing that seemed to motivate him was watching TV and laying on the couch.” Days, she would leave the younger kids with her mother, who is disabled but sufficiently mobile for child care. Ruth Ann soon got a mortgage on a new house. “I am a business owner and a property holder,” she said, smiling. As our interview drew to a close, Ruth Ann produced something from her pocket. “Oh, for heaven’s sake,” she heaved, pressing the buttons on her beeper. “Sixteen calls while I’ve been sitting here!” I wished her luck as she sprinted across the yard to her car. “We made it, you know,” she called just before she got in. “All the way down to my toes, and back again!” She revved the engine, and she was gone.

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.