The machine collapses under the wait of the passengers’ collective despair

They can’t even recommend someone else for you to go to

Please consider purchasing a subscription to support my work and get every issue in your inbox. As a reminder if you subscribe to a year of Hell World you’ll also get a free six months paid subscription to Foreign Exchanges by Derek Davidson and Forever Wars by Spencer Ackerman as well as access to the Discontents Discord channel. Also fuck it why not if you buy a year at the full price today I’ll send you a copy of one of my books of your choosing.

Subscribe now

Over the weekend I watched a stunning film about climate change. No not that one. Although I watched that one too and it was…fine. Not my problem.

The one in question is called Aniara. It’s a 2018 Swedish film based on an epic poem by Swedish poet and winner of the Nobel Prize in Literature Harry Martinson. It goes in part like this:

When afterwards it struck the High Command
that there would never be a turning back
and laws obtaining in the outer field
were different from those in clear control
of placid flight-routines in inner space,
first panic set in, then came apathy
laying between the tempests of despair
its chilly doldrum-world of dead emotion
till the mima, like a soothing friend in need
and filled with specimens of life from other worlds,
to soothe us all unlocked her vision chest.

I don’t want to spoil the film because you should watch it — although maybe not if you’re in a particularly depressed mood — but it concerns a massive spaceship transporting thousands of people from a dying earth to a colony on Mars. Predictably something goes wrong and they are knocked off course. How do all these giant spaceships gets fucked up so easily by like one tiny piece of space trash in every single movie by the way? You’d think they would plan for that. You would think people would plan for a lot of things I suppose and yet here we are.

On board the ship there’s an AI-like device called the Mima which is facilitated by the main character known only as the Mimarobe. It’s a room designed for people to sort of uplink in a way and engage with their own memories of a pre-dying Earth which the Mima can read from their minds and project back to them. When things go sideways and they all end up being stuck on the ship for longer than expected everyone starts to lose their shit after not being able to feel the sun or look at water or birds or whatever so they need the mental respite it provides even more which I certainly understand because I personally reach the point of mental fracture after like six hours on American Airlines. Eventually it becomes in extremely high demand this means of brief mental soothing and before long all of their memories they start feeding back into the AI are no longer of beautiful pristine Earth but rather of being stranded in desolate space and so the machine collapses under the wait of the passengers’ collective despair. The system has become overwhelmed.

When I posted about it the other day someone responded that that sounds a lot like what it’s like to work in mental health care right now and that seemed about right to me and so I called them up to talk about it. They’re a psychiatric nurse in the Philadelphia area who works for a community mental health center. What’s that like? Find out below.

Real quick since we’re on the subject though I’ve been thinking about the term “get help” a lot in the past 24 hours since the Antonio Brown incident. “That dude needs to get help” people love to say. If you missed it Brown who is or was a player on the Buccaneers quit in the middle of a game yesterday which was just the latest in a string of erratic and/or not to mention alleged serious criminal behaviors by the talented receiver. Whether or not he is suffering from a mental health crisis and in clear “need of help” or just a fucking asshole — probably a little of both — has been the subject of a lot of debate today and over the years and that’s not really what I’m concerned with at the moment I’m more interested in the concept of “getting help” itself.

I posted this a little while ago.

What do people think they mean when they say this sort of thing? “You should get help.” “That person needs help.” What help and in what form and from whom and for how long and via what mechanism? To what lengths is one supposed to go to seek out and receive this help incidentally and who is going to pay for it? Antonio Brown can certainly afford “help” but what about everyone else?

I made another half-hearted stab at trying to find a therapist to no avail the other day. A lot of you are probably in the same boat. Once a month or so for the past year I'll try to call up some therapists to see who’s taking anyone on and the ones that bother calling back (maybe 1/10) are always 100% full or don’t take my insurance or don’t work anywhere nearby or want me to do it on Zoom which fucking sucks in my experience. Guess I'll go fuck myself I think and then put it aside again for later.

I nonetheless tried getting help though. Is that what trying to get help is?

Someone posted this in response and I believe it.

“There is a serious crisis in lack of individual therapists in MA right now (I work with some pediatric MH cases that have been on waitlists for almost a year). MH agencies treat their staff like dog shit and most therapists I know are extremely burnt out.”

It’s also something echoed by our interview subject down below today.

A few other responses:

“Ah yes, calling multiple therapists to see who’s open, spending all your money, only to end up with a therapist who doesn’t work for you after having already unloaded all your trauma. Repeat x infinity. Super easy to do with severe unaddressed mental illness!!”

“In my experience, ‘getting help’ often felt like an obstacle course designed by sadists.”

“100%. I told my doctor I was having high anxiety and he said we’ll call you to set up a therapist appointment. Well they never did so I called myself and they said yeah we can get you a FaceTime with someone three and a half months from now. Oh cool, so helpful.”

“As someone who is currently relying on social services for basically everything (I'm sober a month from heroin, homeless in a halfway house/sober living) not only is the system bare bones, it's also designed to push people away.”

“Just call your doctor.”

Regarding those last two replies I also happen to have tried to call my medical doctor today for something unrelated to mental health — although when it doesn’t get resolved it’s definitely going to fuck me up even further in the old brain — and it occurred to me that the waiting on hold music doctors offices and other businesses use is basically the same idea as the hostile architecture you see in cities everywhere to get unhoused people to just fuck off and go away. The aural equivalent of rocks and spikes underneath the highway and shit. Although they actually also do use noise and music to turn undesirable people away from storefronts and such as well.

The point is there’s only so long a person can spend riding the fader on their speakerphone while it cuts back and forth between the staticky recorded voice message “your call is important to us” and the 200w amp volume royalty free smooth jazz before they give up. I tried though.

If you missed this one from last week about how fucking useless the cops are when you call them for their own kind of “help” you should read it. There are also hundreds of more responses to my tweet about it like this one if you want to go gorge yourself on people shit-talking the cops for some reason. Might give you something to do while you’re on hold with your doctor.


One more thing. It’s the two year anniversary of when Trump assasinated Iran’s Qasem Soleimani — just on the eve of Covid before we even cared about it at all — and somehow we didn’t get into a whole fucking war over it and so I was reminded of the opening of this Hell World piece.

On January 1, 2020 the first normal day of the last normal year 177 people were killed by guns in America including people who used the gun on themselves. That’s almost twice as many that are killed on the average day in a typical year in our exceptionally average and typical country but by and large those deaths and the ones on the following day and the following day and the following day were invisible to most of us. No one cares about traffic in a city they don’t live in. Two days after that we assassinated Qasem Soleimani the Iranian general and I remember being worried that untold numbers of people were about to die in the coming months and I was right about that just for the wrong reasons.

“I think it is entirely possible that this is going to be a catalyst inside Iran where the people celebrate this killing of Soleimani” Ari Fleischer said on Fox News that night and then Mike Pompeo went on and said “We have every expectation that people not only in Iraq, but in Iran, will view the American action last night as giving them freedom” and it occurred to me that the way we talk about the bombing violence we export to other countries is similar to the way we talk about the gun violence that we insist upon inflicting upon our own country in that in both cases it always comes framed in terms of extending freedoms and I suppose that’s true in the sense that a bullet and a bomb do provide their target with a kind of freedom.

Refusing to wear a mask during a pandemic is a kind of freedom too.

Ok here’s the talk with the mental health nurse. Good luck out there everyone.

What exactly is your job?

I am a community mental health nurse. I don’t work in a hospital. I did that briefly. I do community mental health work, working outpatient through community mental health centers. Most of the time, by county, there will be a nonprofit agency that provides mental health services. It’s not part of the government. Basically you get the contract for providing services for a particular county. It’s primarily Medicaid funded, and also servicing folks who are traditionally uninsured. I’ve been in that space since before I was a nurse. I used to do case management. I’ve been a nurse for like fifteen years now.

What’s your typical interaction with patients like?

Community mental health centers are generally considered for people who don’t have the resources to go to a private psychiatrist or therapist. Sometimes that’s office-based, like anybody would do. You go in once a month, every few months, whatever. I work in assertive community treatment, which is designed to keep people out of the hospital. You qualify for that if you have repeated admissions to a psychiatric hospital. It’s to try to keep people in their homes, functioning and recovering. I work on managing not just mental health symptoms, but we also have doctors, employment specialists, substance abuse specialists. It's wrap-around. We’re trying to do 90% of the services outside of an office. So I go and see people in their homes.

So you’re a medical nurse with a speciality in psychiatry?

It’s not necessary. Someone with no knowledge of psych could theoretically get into this space. That doesn’t always work well. The goal is to have somebody that is familiar with working with people with severe and persistent mental illness. Right now the other nurse that’s working with me is a long term temp. He’s not actually employed by my place.

It’s a private company you work for handling mental health for the community? Sounds like there’s some potential for bullshit there right? Is it evil or is it only sort of bad?

It’s a non-profit. Uh… I don’t think it’s intentional. I have worked for other places that seemed more or less shifty. I used to work for an agency that decided in the middle of the day one time to fire all of their outpatient nurses. One of my coworkers was getting ready to give an injection. Knock knock. Yeah can we talk to you in the hallway for a second? She was like, can I finish what I’m doing? They escorted them to their cars like they were criminals. The answer they gave was it was cheaper to hire MAs, so they don’t have to pay nurses. Some of these folks had been working there for fifteen, twenty years. That was sick-making. That was when I resigned from that job. I can’t work in a place that obviously doesn’t value my contributions…

Unfortunately with these mental health centers, when the Affordable Care Act got passed, some of these places saw the opportunity for a giant crash grab. There would suddenly be all these people with insurance with medicaid expansion plus being able to buy insurance. They knew there would be more demand, so they expanded as rapidly as possible. But it was like a metastatic growth. They just got as big as possible as quickly as possible trying to get that sweet Medicaid money, without thinking about how to grow in a way that was sustainable and still provided good services.

Of course. That’s how almost everything works now. Like the corporate dental chains I wrote about recently.

Exactly. Whenever you get insurance involved, shit’s gonna go sideways. Dealing with insurance has always been a nightmare. It gets to a point where you feel like your corporate overlords see every employee as this well-trained machine for generating billables. That’s what seems to matter at the top. Then you’ve got fifteen layers of admin who are invested in keeping their jobs and their paychecks, so they have meetings about having meetings about how to tell the people that are doing the work that they’re doing their job wrong, all to justify their own jobs. Because if they’re not managing things, then well… Then it gets down to the folks that are actually providing services. The payscale is terrible. I don’t feel like I ought to be able to complain about my pay and benefits, because as a nurse, I probably make more than my boss, my nominal supervisor, who has probably got a masters in something. Everybody but the nurses seem to be working at least two jobs. Or they’re in school to try to move up a level so they can get paid more. Sometimes both. But as a speciality, mental health is paid way less than medical fields. My nurse friends who don’t work in psych generally make at least twice as much as me.

Have things gotten worse for you all during Covid? Are you getting overwhelmed?

The situation was already bad… Full disclosure, I don’t just work at the crazy club, I’m also a client. I had been living on the west coast and moved back here at the end of 2017. I was out of my meds. First I had to wait three months for my insurance to kick in. Then just to get in the door someplace it was like a three month wait to see the initial screener who would even decide if you got to see the doctor. I don’t even know how long you would have to wait right now to get an initial appointment somewhere. Places aren’t taking new referrals because they’re at capacity. Some of the therapists I work with also do private practice and they’re just overwhelmed. They can’t even recommend someone else for you to go to.

I’ve been having that problem myself. There are no openings! Because I moved about two years ago, I was gonna get a new therapist here, then covid happened, so I waited a while. Eventually I tried doing the telehealth thing and it just didn’t work for me. It didn’t seem real, you know? You go to the therapist’s office or doctor, you take it more seriously than just sitting on the computer you jerk off on all day.

In my opinion there’s something about therapy where you set that time and space and place aside as, like, this is when I’m going to go work on my shit. And there’s sort of, what do they call it, a liminal space. You know, you go, check in at the office, and the setting, I think, can be important. Maybe it would be different if the therapist came to your house and sat down on your couch, but…

Is that what you do? And are the type of people you see in dire need of help at the moment, or just more at risk, or?

Yeah. For my program most of our folks have a thought-disorder diagnosis: schizophrenia, schizoaffective disorder. There are some folks with really severe bipolar, and a few with severe chronic depression. There’s a range of functioning levels within that. We’re supposed to try to graduate them after a while. Get them the skills they need to take care of themselves, then transfer them to traditional outpatient care. The people that could get by with just having a case manager, we can’t move them on now because those programs, like I said, aren’t taking referrals. So they’re stuck with us. There are some folks we go out and see everyday to bring them their medicine. They’re still on that level, like, I need to see you take your meds.

As an aside, I don’t always think concentrating on the meds is the best focus of treatment, but for some folks that’s what we’re doing. Other folks who have more insight and are more willing to engage in symptom management and therapy and stuff like that, that’s being provided in-home, depending on which way the wind is blowing. For a big part of the pandemic we had transferred to a partial work from home program. Theoretically telehealth. We had gradually gotten a few more people coming in every day, but then at the beginning of October, management said, yeah, you can’t work from home anymore. So we came back into the office. Those of us who are left!

Did a lot of people quit?

We have a ton of openings right now. My director, our mid-level management boss, the guy who was previously in that position, an old friend of mine, dropped dead of a heart attack this summer. So that kind of shook things. His second in command had gone out on maternity leave, and when it was time for her to come back she was like, I don’t know about this in-person work thing and bringing something home to my baby. She left. Another coworker just finished nursing school so she’s going on to another position. The guy that was theoretically our lead nurse [moved on] so they’re having me do his position with the vague promise we’ll give you the title and the raise eventually, but nobody ever says when that will come. Another nurse working with me left because of vaccination mandates…

The combination of more people needing care, and fewer people working there, is that owing to covid or?

It’s a chronic problem, but the pandemic has definitely exacerbated it. Not only are we hemorrhaging employees, no one else is signing on. So the response is like, well, we still have to do the numbers.

You still have the pressure to run as many people through as possible to get the insurance money?

Oh absolutely. We’ve got this tally card that says everyone is supposed to get this number of service hours by X amount of staff. But we’ve only got three people working, when normally we would have seven, so all the extra shit gets loaded onto you. When you’re late in getting your documentation done, or you aren’t clocking out after eight hours because they’ve given you twelve hours of work to do, then it’s like, well you’re not performing!

It’s fucked up! You would think it would be preferable to not have as many people needing mental health services for a brief period. Of course they only care about the money, but wouldn’t a very successful mental health service be one that has the luxury of having a light load for a week or two?

Yeah but when does that ever happen? The decisions aren’t being made on the accuity. If somebody is sicker, having a lot of symptoms, and that’s causing problems with their housing, or conflicts with family members, or whatever, then we’re going to be more involved. Sometimes it’s just box-checking. So we don’t necessarily have the time to spend with people who could benefit from the time.

The other thing is, there are things we can’t magically fix. If people say, oh, I need to find housing, I can’t medicate them out of needing to find housing, because that’s a legit concern. If they say I never have enough money, I say, well, you’re right. It’s disgusting what they expect you to live on. People with normal anxiety and fears about the pandemic, there’s no way I can polish that turd. Not for nothing but there are days when I am scared to talk to some of my folks because I know they experience suicidal ideation, and I can’t think of anything therapeutic to say to them. We’re all living through this shit and yes it is bad! I don’t know what to tell you.

Sometimes things really are as bad as they seem.

And that’s the crushing thing. It feels like nobody is driving the boat. Everything is reactive. We don’t have any sort of course plotted. We wouldn’t have had any kind of plan for decreased face-to-face contacts when this shit really broke out if I hadn’t bitched about it for a solid month. I was like this shit is coming, we need to take it seriously. They were like, oh, well, yeah… What got people to take it seriously, I remember this so clearly, I was out seeing people and I came back to the office. There was immediately this weird vibe. Everything seemed very solemn all of a sudden. I was like, what did I miss? They said they canceled the basketball games. That’s what it took for them to take it seriously.

So everything is reactive. And when they brought us back full-time in person it wasn’t based on anything. It was just like, eh, it’s time.

Just based on vibes.

It’s time for all the worker bees to be there.

What other aspects of the job do you find upsetting?

Going back to what I was saying before, it's not being able to help in ways that are meaningful always, if the stress is about finances or your fucked up insurance or not being able to get into the doctor. I help people coordinate medical appointments and stuff. The housing situation is abysmal too. There’s no magic pill to fix your reality. That’s incredibly discouraging. And the persistent absence of any sort of direction from up on high that’s not associated with making sure they get their billables.

That sounds especially frustrating. It doesn’t make it any better but your industry certainly isn’t unique in that way.

Right. I’m sure there were similar concerns back when I started, but it definitely, within the last decade, has gotten noticeably worse.

What might be a step in the right direction in your opinion? Is there something the government could do? They’re always talking about taking mental health more seriously whenever there’s a shooting, then everyone stops talking about it until the next one.

Right. It’s convenient to say, but no one wants to send the money. For all the work we’ve done around mental health with reducing the stigma, it’s still looked at as like garbage medicine.

It’s like, we’ve got all the awareness we need about mental health now, how about just give us some fucking money to deal with it!?

Yes! Maybe if we had just straight-up publicly funded mental health centers, and, I don’t know, paid people more what they’re worth rather than focusing on let’s get warm bodies in here?

It’s always about the fucking money! But as far as what the government could do, maybe make life conditions less horrifying for everybody!?

That certainly would help with a lot of people’s mental health.

Don’t create trauma for hundreds of thousands of people and just expect it to all come out in the wash!?

One more thing I wanted to ask because it’s been on my mind again lately. I assume you agree that sending the cops out when someone is undergoing a mental health crisis is absolutely fucked?

Oh Jesus, no! I will do almost anything to avoid involving the police when it comes to a crisis.

Have you seen it go bad?

In Philadelphia this year or so there was a bad shooting due to a mental health crisis. When I was out in Washington there used to be shit all the time with cops killing people in the midst of a psych episode. None of the folks I work with personally have gotten killed, but one of our participants was tazed in her own apartment pretty badly. She was traumatized by that. Another lady I worked with who was homeless had the cops set dogs on her. Ripped a massive chunk out of her calf. And then I’m trying to track her down. She’s living in the woods. She was like, oh, it’s good, my mom taught me first aid! The resilience of this woman, to heal an injury like that while living outside. But people shouldn’t have to do that.

No, of course not. And you know better than we do, dealing with people with mental health problems, the last thing that’s going to help when someone is agitated is for cops to show up with guns. That seems counter-intuitive.

There’s a program called Mental Health First Aid where, in some areas, they’ll have classes primarily geared toward first responders, EMT, fire, cops, but also school teachers. People who interact with the public and may have some sort of role to play if there’s a mental health crisis. It’s like how to respond to that without making the situation worse. I’m not sure if there’s data on how much that helps. Or if it can be trained. I can’t train you to give a shit about other people. Maybe that’s just my pessimistic thinking about law enforcement.

I don’t know if you can train people to care.

But yes the last thing I want to do in an emergency is call 911. If at all possible, if the person needs to be assessed for involuntary treatment, if they might really need to go into the hospital, I’m going to do everything I can to try to get them there without involving the police.