My Nerves Are Bad: Puerto Rican Women Managing Mental Illness and HIV Risk

7. Adrift: Navigating Systems and Bureaucracies

111 7 Adrift NavigatingSystemsandBureaucracies It is a waste of time talking to my social worker because Puerto Rican families don’t do some of the things she suggested. —Mireya Accessing Services Numerous reports have documented alarming deficiencies in the availability and provision of mental health services to those in need of them. As an example, among individuals with depressive disorders who are seen in general medical practices nationally, only about 50 percent are actually recognized by their providers as being depressed, and only onehalf of them receive appropriate treatment; this means that 75 percent receive either no care or inadequate care.1 Studies have consistently shown that Latinos are much less likely than whites to receive appropriate care for mental illness.2 And, among those who are depressed, Latino patients are less likely than non-Latino white and African American patients to receive specialty care for their depression.3 These deficiencies are even more pronounced among those who are poor or uninsured.4 The women in this study met with numerous obstacles in their attempts to access both mental health care and other needed services. Even when they were able to obtain services, the adequacy of those services was sometimes questionable. As an example, one of the study ethnographers became concerned during a shadowing episode that Yadra, who suffered from major depres- 112 “My Nerves Are Bad” sion, might be on the verge of a suicide attempt. She obtained Yadra’s permission to call the hotline for the crisis unit, hoping that someone there could intervene appropriately since Yadra’s mental health care provider was inaccessible. The ethnographer’s notes reveal the futility of that effort: “I called the mobile crisis unit from her [Yadra’s] house. The worker that answered said that since she [Yadra] has a mental health provider and it is still during business hours, she needed to contact them to make the assessment on her. He said their services would be on an after-hours basis if she would not be able to get in touch with the office of her mental health provider.” The only option remaining to Yadra, like many other severely mentally ill individuals with poor access to outpatient care, was a visit to the emergency department of the local hospital.5 This was not the first time Yadra had had such difficulty contacting her provider. The ethnographer’s notes had documented other, similar instances: “She [Yadra] said that she has called her social worker over eight times and she has not returned her calls. She said that she could no longer leave any more messages because it says that her mailbox is full.” The long waiting time to be seen at the emergency department of local hospitals frequently complicated efforts to obtain care. Longer waits meant taking the younger children along, and that could mean spending more money on transportation to get there. Leaving them at home meant that they would be unsupervised for a longer period of time, and that could mean more issues with child protective services. Marisa, diagnosed with schizophrenia, had three young children at home. She prevailed upon our ethnographer Isa to take her to the emergency department to be seen for the severe abdominal pain that she had been having for several weeks already. She was finally able to go, she explained, because her father was visiting her from out of state and could watch the children while she was at the hospital. By the time Marisa was seen at the hospital, almost four hours had passed since her arrival there. It was some time later that she was informed that she had a bladder infection and that she was able to obtain the medications necessary for its treatment. Stigma Even after accessing services, clients with severe mental illness may continue to encounter barriers. One might think—and even ex- Adrift 113 pect—that professionals in the mental health field would approach their clients non-judgmentally, understanding the embarrassment, the fear, and the isolation that often accompany symptoms of mental illness, even before a formal diagnosis is made by a mental health professional. Even mental health care professionals, however, have been found to be stigmatizing of their clients, using pejorative terms to describe them or their symptoms, disbelieving their physical complaints, ridiculing their mental illness symptoms, and devaluing their efforts to achieve a more stable existence .6 In one study of mental health service consumers...