Everywhere in Chelsea, the TV sets are on all the time. Children walk and talk like cartoon animals, and their mothers are as absorbed with the vicissitudes of soap-opera lives as with their own. I visited the home of a family in which a 21-year-old woman had hanged herself the day before. Grief, rage, longing, and guilt were suffused with the blaring sounds of a hysterical daytime quiz show. The audience applause hung in the air like satanic mockery. Family members were reluctant to turn the set off during our talk.
I started work as a psychiatrist at a community mental health center in Chelsea in the fall of 1975. The basement of a simple white church became the center of my professional life. Behind a wrought-iron gate and up a few Baptist-modest steps, the Horace Memorial Church stopped visitors with this hieratic notice board on its wall: "MENTAL HEALTH IS AROUND THE CORNER."
I was greeted by a committee of the staff. We met in the kitchen, which I soon learned served as the conference room, staff lounge, day-treatment center, and occupational therapy room. They were not particularly cordial. Finally, they asked the question that underlay their reserve: "How long do you intend to stay? Can we count on you for at least a year?"
They surmised that I was merely idling between high-powered jobs or, worse, collecting information for a quick book. They found it difficult to believe that I was prepared to spend a significant portion of my career in this kitchen. But I was to stay for 16 years, remaining after all of the original cast of characters, including the minister, had left.
Ellie was not my patient. Her mother, Victoria, was a chronically depressed, bedridden woman paralyzed by multiple sclerosis. For four years, I made weekly home visits to Victoria, who had been referred to me after a serious suicide attempt. Victoria and her common-law husband, Larry--Ellie's father--owned a nickel-and-dime variety store where cigarettes, soda, lottery tickets, and candy were sold from early morning to late at night.
Larry had given up his manual-labor job to run the store in Vicky's absence. She became paranoid about money and, before long, paranoid about the many single women who would stop by the store. As it later turned out, Larry was indeed sleeping around, but Vicky's helplessness and rage at her own body had resulted in furious fights even before her fears were realized. It was after such a fight that she'd attempted suicide. Thereafter, she would constantly threaten to swallow all of her (many) pills or leave on the gas jets so "he can have the store and his girlfriends and Ellie, too."
Ellie was nine when I began my visits. Her room was small, separated from the chaotic bedroom of her parents by a thin plywood wall. All the groans of pain and ever less frequently of pleasure came through that wall, and much of my futile effort as a psychiatrist went toward developing in the couple a sense of boundaries and responsibility toward their daughter.
For years Ellie saw it as her responsibility to keep her mother alive. Coming home from school, she would count her mother's remaining pills and check the gas jets before she threw down her books. It was, she said, the hardest part of her day, the scariest.
My conversations with Ellie were always over her shoulder. She never really wanted to talk to me and refused my suggestion that she come to the clinic to see one of the "big sister"-like counselors. She saw therapy as something for people like her mother.
Ellie was getting A's from the nuns at Saint Rose School, but they complained on report cards that she was preoccupied and distracted. Too much of life was forcing itself too soon on the delicate filigree of her preadolescent mind.
Once I asked, "Ellie, do you ever think about your future?"
A shrug. "No."
"You could go to college. You can do anything."
"I'm not that smart."
"You're very smart. College would be easy for you, and there are scholarships to make it free. Don't you ever have dreams about grown-up life?"
There was a long pause. "I dream of being a secretary."
This was her sense of the vast, inaccessible world of middle-class life: the TV world of a secretary, with its bogus glitz, modern apartments in the city, and charming, successful men wanting to marry her. Such was the hidden injury of her class that the polished image of a clerical functionary at the lowest level of that world felt impossible. In her mind, her future would more likely be spent in factories or, as it turned out, in pregnancies and on welfare. That was a future she could create for herself. She began it four years later, at the age of 13.
What could she say? Perhaps, "Take your smug face, your glib insight, and go to hell."
There is an uglier form of violence in Chelsea and similar places. The combination of density, racism, poverty, and youth equals mayhem. The young people of Chelsea look around and realize what is in store for them: a trap.
Jerome Kagan observed child development in different cultures and concluded that social class is the implacable predictor of an individual's sense of mastery over events. When children learn as early as six that they are the playthings of destiny, that external forces determine their security and satisfaction, they develop no sense of purpose and no capacity to think of the future.
The mind is as much a social as a neurological structure. Our mental life resides within the relationship between society and the individual nervous system, and both mental illness and violence disrupt that relationship.
Some people have compromised nervous systems, a feature of which is the inability to filter stimuli and respond in a controlled and functional way. Damage to the cerebral cortex, where ration-ality and civility are rooted, results in an uncontrollable and often destructive response to a minimal stimulus.
But the propensity to violence, the too quick-and-easy resort to it, at times reflects a nervous system that has been damaged as a result of poverty--for example, by compromised reproductive health. Children who bear children have a higher rate of all pregnancy complications, each of which threatens the health and neurological competence of the infant. Poor health in the mothers--from inadequate health care, deficient diet, exposure to pathogens--intensifies the problem.
There is a trap in such an inquiry. Identifying a neurological dimension to violence must not lead to a public-policy preoccupation with the individual manifestation of such defects. Rather, it should explore their shared and social origins. The focus must be on poverty, not on its victims.
Early in 1992, consistent with the times and with the ideology of the administration that appointed him, the director of the National Institute of Mental Health commented that his agency would try to illuminate the causes of urban violence by searching for "biological markers." By age five, a child (most likely poor and black) could be identified as a future perpetrator of violence, and preventive intervention could be attempted.
This represented a reprise of the research done on prisoners that tried to relate an extra Y chromosome to criminality. And it shared in the tradition of research on "protest-prone students" and the suggestion made by psychiatrists during the civil disorders of the 1960s that rioters might be suffering from temporal-lobe epilepsy.
I became involved with the DeAngelo family when their 10-year-old boy, one of four children, was found playing with matches after causing a fire that had burned them out of their previous apartment. Mrs. DeAngelo was a massive woman, always at the kitchen table, always smoking or playing solitaire.
Her husband was a small wraith of a man, a factory worker at a company that manufactured chemicals. There was a perpetual smell about him, something sweet and volatile--benzene, toluene, or acetone. I was later involved in a strike at his plant when the owners refused to acknowledge that these were hazardous substances and would not provide masks and gloves to their workers. But at that time, I merely noted as another source of stress that when Charlie would walk into the room, his wife and two of his children began wheezing from chronic asthma.
Behind the house was an auto junkyard where frequent fires occurred, usually involving tires and lead batteries. Every time I left the house, I had a headache. I could never tell whether it was from the noxious, nauseating mix of vapors in the air or frustration at what I was doing there.
The children had a pale, pasty look to their chubbiness. In the refrigerator were Pepsi bottles and peanut butter and luncheon meats. There was always candy on the table; the children reached for M&Ms with the same habitual joylessness, the same lassitude, with which their mother reached for a cigarette.
On one occasion I "lost it." Mrs. DeAngelo was telling me how much trouble she had getting her children to come in from the street (the highway) each night for supper. An ashtray with a half-dozen butts ground and broken like bodies after a disaster was in front of me. The acid stink broke through and burned my eyes.
"Goddammit, Marie," I said. "If you were a little more controlled in your own behavior, you might have more control over the kids. You could cut down on your smoking. You could drink less Pepsi. You shouldn't talk so much about sex in front of them." My voice rose.
"You should have clear-cut sanctions for the kids. If they aren't in by five, no television. They should have tasks around the house. They should do their homework. They shouldn't be out there in the dark."
What could she have said? Something like: "I didn't ask you to come here and tell me how to run my life. Who gave you the right to judge me? Take your controlled, healthy, smug face, your glib insight, your condescending, self-important arrogance out of my house and go to hell."
She actually said nothing. She looked at me with a small smile and then blew a long, slow stream of smoke into my face. I laughed. Then she laughed. The sounds of cartoons on the TV came from the other room.
To be mentally ill is to feel one's membership in society up for question. It is to be marginal, deviant. A mental health clinic cannot be expected to function as a model of utopia, but it can at least try to minimize the forces of alienation and mute the discords of a society that is endlessly exclusive. These are not the technical issues of psychotherapy or medical management; they are human ones.
This is why the managerial demands of productivity are so inappropriate to mental health. They frustrate the essence of social psychiatry and community mental health, that is, mental health not just in the community but of the community. Accountability in such a setting is not to a business manager or to a computer program, but to one another and to the community, perhaps even to the idea of community.
I cannot say that such an environment existed at the Chelsea clinic. But at least we were struggling toward it and, at times, seemed to approach it.
The struggle came to an abrupt end in 1991 when the governor of Massachusetts laid off 800 state-salaried mental health professionals working in outpatient settings. The clinics, among them the Chelsea Community Counseling Center, were to be downsized and privatized.
And now, as if the capacity to regress were endless, Massachusetts and other states are closing their state hospitals. We are returning to a pre-Dorothea Dix era in which the mentally ill are once again in shelters and jails and on the streets.
This is part of the systematic destruction of a social infrastructure for the urban poor. The welfare system is being dismantled at the moment when ever more helpless human beings are being generated. Child welfare agencies, with all their contradictions, are being devastated as more abused and neglected children are forced upon them. We are laying off teachers and closing schools while we open more prisons. This is the legacy a society in decline leaves to its children: the disruption of the gossamer network of mutual responsibility that we call "community."
It was not easy to say good-bye to Chelsea. After 16 years, I had become connected in ways I would not have guessed. I would walk down the street and people in windows would wave at me. The children of patients I had known as children would pull on my coat and giggle.
On one of my last afternoons, with spring softening the edges of the city and dormant smells beginning to stir, I got a whiff of something familiar. It was the scent of white port from Joe's breath as he shuffled down the street.
I called after him. "Joe, I have to tell you something. I may not see you again. I was laid off. The clinic is going to close."
"Where do I get my pills?" He meant Dilantin for his seizures. He routinely asked for Valium, and I routinely denied his request. It was a ritual.
"You'll have to go to the clinic at Lindemann."
"I won't go to that dump."
He laughed. "What's funny?" I asked.
"A state is really going downhill when they start laying off garbagemen."
"What do you mean?"
"You've been taking care of garbage. Me. Waste. They throw things away. People, too. You're supposed to keep the garbage off the streets. And they can't even afford that now. So the garbage piles up."
"I never thought of you as garbage, Joe."
"I'm garbage, something they don't need and don't want. And guess what? You're garbage, too, now."
I did not feel offended.
Matthew Dumont, M.D., was known to his readers as Dr. Hugh Drummond when he wrote a regular health column for Mother Jones. This article is adapted from "Treating the Poor,"available through Dymphna Press, Box 44, Belmont, MA 02178.