Here Katie Alice Greer unpacks the complexities surrounding mental healthcare, recounting her own struggles with mental illness and the need for artists to have an accessible, well developed mental healthcare system.
Guest post by Katie Alice Greer for CASH Music
I am pretty good at talking to myself. This basically means I keep a character in my head who is rational, loving, and no-nonsense; she is me, but she is also talking me down from the proverbial ledge in times of duress. As a kid I was not so good at this, and in fact the character in my head was a downright bully. I talked to me about how I wasn't good enough, wasn't disciplined or strong enough, wasn’t trying hard enough. I stoked every competitive ember in my being with self-talk about hurting myself into being “better.” It took a long time and concerted effort to re-groom this “other self” into my best friend rather than my worst enemy. Talking to myself is a practical, inexpensive, and readily available way for me to always know I can help myself. You develop these kinds of survival techniques when other resources are out of reach.
Lately I'm doing well. It doesn't mean I'm happy all the time, but I am able to work and my personal relationships leave me feeling supported and fulfilled rather than anxious. Mostly I sleep okay. My mid-twenties were far more turbulent, however, and long untreated depression was extremely disruptive to my well-being.
This is a personal problem but also a social one, which is mostly why I’m writing about it at all. I’m not usually too keen on sharing this much about myself in longform essays, but I have a feeling many other people deal with related issues and we all just assume this is how it has to be. I want that to change, I want better systems for all of us.
I want us to talk about mental illness the same way we talk about anything from a common cold to cancer.
Untreated mental illnesses are just as deadly, and often completely ignored.
That my most reliable coping strategy was an initially self-harming practice of talking to myself is not so much a testament to my own resolve as it is to the shamefully inaccessible, virtually non-existent U.S. mental health care system available to most working class laborers in creative industries.
Many writers, painters, musicians, actors, and generally self-employed neuro-atypical thinkers are getting by, just barely, without any sort of help or support system from social institutions that should address mental health-related illnesses. It is a battle to find proper mental health care for those who are already working at a deficit, and these services are often too expensive to be of any use at all.
Two years ago, after many months of shifting through life in either a dissociative fog or unending sadness and despair, I finally tried to find outside assistance. At that time I couldn’t prove I was an official resident of any state, so I was not able to sign up for health care through the Affordable Care Act. I'd purchased a one-year health insurance plan that, after many phone calls to different providers, proved to be fairly obscure and infrequently "taken" by mental health professionals in my town. Miraculously, after many web searches I finally found a woman whose life in international social justice struggles I deeply respected. I couldn't believe my luck. Ruth (name changed) was in her eighties. She had a lifetime of experience in prison reform policy work and published feminist writing about global violence against women and the psychology of politics and creativity. I was fascinated, and knew that if I were to open up to someone, I needed to admire and respect them. Perfect.
The longer I am alive, the better I can tell the difference between what is OK Sadness and Not OK Sadness. With OK Sadness, I still get stressed, I get grouchy when I’m hungry, I’m occasionally afraid, tired, bummed about something, angry about the fucking president. These are fine. The Not OK Sadness and related emotions feel like I am drowning in a dimensionless, infinite ocean. No one and nothing is good. There is seemingly no way out. Severe depression, bipolar disorder, and high anxiety run in my family. For me personally, OK Sadness means the machine in my head is working just fine and Not OK Sadness means, just like a runny nose, upset stomach, or a hacking cough, that I am currently sick. Plenty of factors both genetic and environmental mean I’ll always need to keep an eye on how things are going in my head, but truly any person is at risk for mental illness, the degree to which being determined by any number of factors in the stressful precarity of daily life. All of us should be socialized to be cognizant of how we’re feeling in the head, just as much as any other aspect of physical health.
I had been crying in the bathroom a lot at work when I finally started looking for a therapist. There is nothing inherently abnormal in this, and perhaps if a loved one had died or I were going through a breakup this would have made perfect sense. But it was bottomless sadness, and there was no particular reason beyond abstract despair for what was happening in my life, maybe in all of our lives. If you had asked me why I was crying I might have said something about the crushing machine of capitalism. Like, yes, of course, be sad about this, but not at the risk of getting your paycheck.
I visited Ruth’s office in her home, elaborately furnished with colorful paintings, sculptures, stocked bookshelves she would eventually let me borrow from, and two white and grey Himalayan cats who wandered around her beautiful Turkish rugs. She explained that she was deeply passionate about the need for creative workers to have access to mental health professionals. She said she accepted my limited insurance but also wanted to take into consideration my income, and would only charge me a $25 co-pay in cash per weekly visit.
$25 a week, plus the cost of transportation and taking off at least half a day of work for travel to this appointment, was still more than I could actually afford to pay by waiting tables in a restaurant when I wasn’t on the road with my band. But I couldn't believe my luck. I knew that I really needed help at this point and that I was often too uncomfortable to ask for it. During the first few calls I made to therapists offices, my voice cracked and stuttered. I swallowed back tears and felt panic at my inability to explain why I was calling at all.
Surely I sounded like a fraud, like a baby demanding attention and taking time away from real people with real problems. This is all part of the stigma around proper mental health care, the idea that only a small number of people actually need mental health care, and you are being weak or selfish if you are seeking it out at all.
Nothing is further from the truth. Mental health is part of physical health. All of us should take it into regular consideration.
GOP plans to overhaul the Affordable Care Act (aka Obamacare) were mercifully stifled last Friday, when the repeal bill was withdrawn before a vote because it would not have won enough votes to pass in the House of Representatives.
While this is certainly a small victory we should celebrate, it isn’t a signal to shift conversations away from making affordable health care a human right for all people in our country (single-payer, anybody?).
The next four years and beyond will necessitate a fight to keep what is already providing care for millions more Americans, and expand coverage in ways not already written into law.
The GOP’s faulty plan was designed to eliminate (among other essential services) mental health care coverage for working class people who need it most. The Mental Health Parity and Addiction Equity Act, signed into law in 2008, requires health insurance plans to cover mental health and substance abuse treatments the way they would cover other chronic physical health issues. Providers cannot charge more for these treatments, or limit the number of visits to a mental health care professional if regular treatment is needed to manage chronic mental health issues.
While the GOP’s plan couldn’t repeal MHPAEA, according to Psychology Today, by 2020 it would have removed the requirement set forth by the ACA that requires Medicaid to cover at least basic mental health issues. The Harvard Department of Health Care Policy estimated at least 1.2 million people who receive behavioral health treatment through Medicaid would lose services. This is sort of like leaving the entire combined populations of Boston and Washington, DC without mental health care.
Even most Republican members of the House of Representatives in a fiercely partisan political landscape couldn’t support House Legislation 1275. This bill was defeated, but the GOP’s severe lack of concern for mental health spells out immediate danger for those of us who can’t afford costly therapy, psychiatry, medication, or the basic time and space necessary to process and heal whatever isn’t working properly. Working class creative people (often neuro-atypical by definition of their “outside the box” thinking) are at extreme risk when they are not afforded a social system that attends to mental health support.
The USA needs more open discussion about mental health, something the creative class has long championed by virtue of its work and livelihood. I’ve had conversations with most of my close creative-laborer friends about struggles with mental health. Talking to another trusted person about depression, anxiety, eating disorders, surviving sexual assault, addiction, suicidal ideation, self-harm, paranoia, post-traumatic stress, parsing out delusion from reality, and just about any other mindful struggle one can conceive of is necessary for getting on with life without your mind consuming you. But for many, finding an affordable and effective mental health care treatment plan is difficult at best and impossible at worst. My friends have often been my therapists, and I have often been a therapist for my friends. It is a lot to deal with. I wish we all had a better support system, but I’m truly grateful for the relationships I’ve built with people and how much we’ve struggled through together. Still, I want more for us.
While essential for survival in a nation state that financially prioritizes war over people, self and community reliance are not enough. We are being robbed of our health in the name of national security.
Though I have lots of artist friends with whom I’ve shared vital mental health related conversations, I don’t mean to suggest this talk happens in public or is free of discomfort. Most of us are not socialized to be immediately aware of these problems or have the communicative tools to readily articulate what’s happening in our heads. It involves a lot of patience (with ourselves and with others), and it involves a lot of digging.Though they are just as common as a viral infection or a cold, the stigma and shame around treating mental health issues make already inaccessible care that much more out of reach, particularly for working class people, like many creative workers.
Equally troubling is the commonly perpetuated myth that all “good” artists are pretty fucked up, either to themselves or other people, and that their untreated mental health problems are the reason for their genius rather than a hindrance to the work they could actually create when healthy.
A pop culture constantly romanticizing artist self-destruction is deadly. It encourages artists’ harmful behavior, and discourages seeking treatment that would actually improve both their livelihood and work. Just ask David Lynch: healing mental disturbances and finding an inner peace of mind is the bedrock of sustained creative practice.
When I finally sought out a therapist two years ago, I felt like I was in too deep to ask friends to help me. I felt incredibly unmotivated to call up most offices, but Ruth seemed different. After reading about her work, I genuinely wanted to talk to this woman. Not even about my problems. She seemed like a perfect therapist for me, despite being someone I normally couldn’t afford. Her benevolence in seeing me was humbling. I thought perhaps she didn’t need money. I was relieved to think we could talk about stuff I was actually interested in and, I hoped, eventually unpack what the hell was the matter with me. At this point it was often hard to remember what I even cared about at all. Anyone who reminded me I was still a living person with interests and passions got my full attention.
I paid $25 per weekly visit where she told me about meeting Yoko Ono through NOW events in the 60s ("she was smart and kind"), Betty Friedan ("more interested in fame than feminism, not a nice person"), transactional analysis, the relationship between aesthetics and ethics, and traveling the world. I enjoyed the stories very much but also wondered if I should direct our conversations more toward my personal problems, since my near-constant sadness was almost totally debilitating my ability to work or generally function around other people.
After one session centered around a 45-minute tale of visiting Mexico with a piggish boyfriend and ditching him for a guided tour by a young boy who later turned out to be El Chapo (literally no way to verify this story), I started to wonder about Ruth a bit. I was still terribly embarrassed about needing help in the first place, especially because I didn't totally know what my problem was. Endless sadness but why? Many things, but also nothing, really. I hated to talk about it out loud, but I forced myself to explain more of myself each week, even when my petty, shallow human-ness felt embarrassing to acknowledge.
I’ve been around long enough at this point to know when I’m generally “OK” and “Not OK.”
OK: seeing patterns and relationships between unrelated entities; I like being able to think this way because it is useful for songwriting, among other creative practices.
Not OK: a paranoid certainty that observed patterns and relationships indicate the world is locked in rigid opposition against me, or general humanity. I am positive that there is no way to survive, for me or anyone else. There is quite possibly no point to living, no point to anything. I have no agency in my life.
OK: inspiration from any crevice of the world's surface, the graphic design on the side of a highway semi-truck, the syncopated whoosh of the dishwasher, a vocal melody in the pop song playing at the grocery store, good music, bad music, ugly fashion, haute couture, terrible news networks, avant garde cinema, all of the parks and museums of Washington, DC. I love it all. I can make use of something in anything.
Not OK: I am certain I will never write a song again, I hate everything in the uninspiring world, including everything I commit to tape or paper. All of my horrible side jobs will spiritually kill me before I can ever make anything good again. Also, whatever shitty job I have will certainly be my job forever, this is outside my control.
OK: I appreciate the utility of, but am not terribly concerned with social media.
Not OK: I have gone through periods where, under high stress, I wonder if people I don't know very well are talking to or about me, possibly in code. I’m frightened by this possibility. I get wrapped up in searching for negative reviews of my work. A horrible game: easily ignore ten nice things said about something you’ve made, keep searching until you find the nasty one that stings. Log off satisfied that this, the meanest thing, must be the truth.
Sometimes I have even been plagued by the incredibly convincing idea that no one who says they care about me actually does, that no one will ever truly know or love me. My sadness often takes on a grandiose dimension, something that seems so melodramatic once I’m feeling better: “no one loves me” spirals into “love isn't real,” spirals into “humans are only cruel and exploitive,” “how can my values square with an already defeated world,” “what is the point of living,” etc.
Sometimes when I arrived Ruth would speak slowly that day, like her batteries were running low. On those days if I talked for longer than 30 seconds at a time, her eyes would glaze over a bit and she would snore.
“Ruth?” I would ask, leaning closer. Her eyes would open again, she would speak at a normal pace as if she hadn't been sleeping at all.
While highly disconcerting, on some level this was darkly amusing. I didn’t know if this was normal for her or whether or not I should let somebody else know, but on larger level I knew what was going on. Here I was, stubborn woman who took too long to “get help” she can’t afford, finding an equally stubborn woman who refuses to retire and won’t charge a lot but probably can't help much at all. Ruth was not negligent or unconcerned with my problems but was constantly battling someone—her children, other clients or contractors—who didn't want her to work anymore. She lived alone. I intuitively understood why she was determined to keep working. What else is there to do? I was fond of Ruth and found us to be an unlikely but similar pair. One day she decided that because I liked music, we should go upstairs and listen to records. We sat on her bed in uncomfortable silence as “I Am Woman” played from a small Victrola. She was not well-equipped to treat me but she was kind. I appreciated her gestures, and I couldn't afford to look elsewhere.
Twice I took the long bus ride to her home only to learn from the housekeeper that Ruth was not taking sessions today, as she'd been rushed to the hospital in the middle of the night. She delivered this news like Ruth had gone to run a few errands, as if it were totally normal. I should've found another therapist at this point, yes, but I strongly doubted I'd find someone else who charged so little, and apparently under the table, at that. I didn’t really understand my coverage but hadn’t gotten any notice from my insurance at all. Plus, I thought she was a good influence on me, and I could tell she really liked to see me.
When Ruth asked if I would like to move into the English basement apartment downstairs, I sadly realized that this was truly no longer a workable arrangement. It is never a good feeling, wondering if your therapist needs you more than she is able to help you. The USA's negligence of mental health care is similar to negligence of our aging population, members of whom are often isolated and under supported. I felt bad, but ultimately knew I was in no position to be helpful to Ruth and decided it would be best to add more distance to our relationship.
I had a show in California and didn't schedule more appointments after my return. I still liked Ruth but needed to save money. After two months of no visits, the night before I was to leave for a tour in Europe, I got a frantic email from Ruth explaining she needed to see my health insurance card again immediately, that she absolutely needed to file paperwork before the deadline so that she could be compensated by my health insurance company. Upon returning home from the tour where we'd done a little better than breaking even after expenses, I was mailed a bill from my insurance for $3,000.
"I don't understand this," I said to Ruth on the phone after initially sobbing on my bed, clutching the bill like a personal death certificate. Was she sending me this because I'd stopped visiting? "I paid each week and you said— you understood I didn't have a lot of money." I was terrified. Ruth often asked me repeated questions about my personal history, so I knew her memory was not at its best. Had she forgotten our initial arrangement? Had I misunderstood? Fuck.
“This is for many months of my care,” she said, as if this explained the extraordinary expense that had never previously been communicated to me.
"I don't have $3,000," I said firmly. She paused. Sometimes it took her longer than what seemed normal to speak.
“I know. I think it was a mistake, from your insurance company.” She was back to her other self, the one who was enormously compassionate. The one who told herself that she had to keep working because too many people who needed help couldn’t afford it. It seemed like there were two Ruths, although they didn't always communicate with each other. “Resubmit the bill and call them,” she said. “They should pay me and we will be all set."
Ruth was wrong about my insurance company paying her. It turned out that because I had no regular physician to diagnose me as a person suffering from severe depression, seeing Ruth was not actually covered under my plan at all. Crying in the bathroom at work daily, disinterest in almost everything, rarely leaving my house, and having trouble most days getting out of bed were not symptomatic enough for coverage, but because Ruth had not processed my paperwork in a timely manner, none of this was communicated to me. Until I paid a doctor to hear me explain this and agree it was debilitating to my life, none of that counted for much of anything. Ruth either wasn't aware of this, or after our initial visit, decided she didn't care. The insurance company advised me to take it up with her.
I never heard from Ruth again. I hoped she somehow got her money but knew that ultimately if she didn't, she still had more than me.
Ruth died last April. I found out through a friend accidentally bringing me to her home for what she'd described as “the best estate sale I've ever seen.” When we pulled up to Ruth's address I nearly fainted.
Like I said, she was stubborn as hell and I am pretty sure she was busying herself with whatever work she could get her hands on up until her heart stopped beating. No one has since contacted me about this bill and if I were a religious person I would be praying every night that they never do, or at least hold off until I have any sort of savings account.
These are the sorts of psychotic risks people take on a regular basis when they have no safety net. An instinct for survival, on a physical, psychological, and emotional level, will influence all kinds of seemingly bad choices, instigating incredulous questions like "Why in the hell did you do that?" and "What were you thinking?" As if either of those answers are not simply, "Money."
I always have to keep an eye on my mind, but I feel better. I worked through some shit, some of it was with Ruth even when she fell asleep, some of it was on my own, some of it was with the help of my patient and loving friends and family. Nobody has asked me to pay this bill, which, even now that I am more solvent, would wipe me out financially. So, I am lucky. I still do not have much money, but I do not cry on a daily basis for reasons I cannot explain, I am emotionally and psychologically stable, and I can do the work I need to do to support myself.
I have not searched for a new therapist, but I did finally get proper healthcare through the ACA last year (Medicaid) and I am trying to understand what mental health coverage is provided so that I do not find myself in this situation again.
I continue to most heavily rely on my own personal strategies for psychological survival. I know I can keep talking to myself, my friends, I can write, exercise, learn about meditating, eat well, etc. I take solace in these self-sufficient strategies because horrific legislation motivated by profit over people will not strip them away from me.
Mental health care, like all health care, is a human right. I am heartened to see that a bill designed to slowly eliminate mental health care for poor people was defeated, but the struggle to make mental health care accessible for every person in the U.S. is far from over. Without affordable, accessible care, people will die.
Provisions for mental health care are essential to a holistic health care plan. Concern for a healthy mind (and therefore body) is a consideration still too expensive for most, both financially and socially. Mental health is not a specialized interest for a tiny segment of the population. The continued silence and stigma around mental health care issues perpetuates a social illness and falsehood, that only a small number of us have mental health issues at all. Health care, including mental health, is a human right. A big "fuck you" to any government that continues to suggest otherwise.