New Haven’s low income, uninsured, and migrant communities shoulder the burden of extra mental health challenges during the pandemic.
After shuffling through some pages, Dr. Michelle Silva found the passage she was looking for. “Trauma waits for stillness,” she read. Silva is a clinical psychologist at the Hispanic Clinic of the Connecticut Mental Health Center. The bookshelves in her office—packed with clinical files, tomes of Sigmund Freud and Ignacio Martín-Baró, refugee children’s books, and novels like American Dirt, from which she had just read—neatly framed her Zoom background. “Usually, people can find ways to cope and keep busy,” she said. “But isolation can be stillness in some ways—a forced stillness.” As a psychologist with an interest in attachment theory and liberation psychology, which engages with themes like systemic oppression in marginalized communities, Silva wondered how the current pandemic would complicate an already challenging mental health epidemic.
Quarantine, lockdown, and self-isolation, while essential to viral disease control, can be deleterious for mental health. Humans are social creatures, and the pandemic is forcing people to act against their survival instincts—to turn away from others. A recent epidemiological review by Dr. Mahbub Hossain and colleagues reported that those quarantining in isolation suffer greater levels of anxiety, depression, trauma, and other adverse mental health outcomes.
On March 23, Governor Ned Lamont issued a statewide stay-at-home order. By early summer, New Haven schools and universities emptied. The streets were quiet, the silence broken only by police cars and their projected bilingual recordings of Mayor Justin Elicker urging people to social distance and wash their hands in both English and Spanish. Almost six months later, Connecticut’s consistent and precautious COVID-19 response has placed it among three other states that are ‘on track’ to contain the virus. But the social and psychological repercussions of an indefinite pandemic have taken their toll. Although reports like those from Mental Health America rank Connecticut among the states with best overall mental well-being, the pandemic has had a deeper impact on the mental health of New Haven’s low-income, uninsured, and migrant populations, who already disproportionately endure psychosocial stressors.
The pandemic and the economic downturn it catalyzed have incited skyrocketing rates of unemployment, income loss, and food and housing insecurity. Within the New Haven Latin American community that the Hispanic Clinic serves, legal status and loss of community only exacerbates patients’ daily trials. “When we think about legal status,” said Silva, “there’s a real investment, in the current context, for them to try to keep a low profile and remain invisible if they can. The pandemic has heightened that sense of separation, of isolation, and been really, really challenging for people.”
Even procedures like contact tracing, which the Centers for Disease Control and Prevention (CDC) has signaled as a key factor in slowing the spread of COVID-19, pose a perceived risk among undocumented immigrants seeking treatment. A phone call asking an undocumented person whom they have been in contact with may force them to choose between their public health duty and their family’s security. Having to grapple with a choice between one’s health and legal status, on top of everyday financial stressors, can be an anxiogenic experience.
For Silva, seeing her patients struggle with these issues is particularly personal. Born to Ecuadorian immigrants in Connecticut, she grew up speaking Spanish and English. However, with her bilinguality came responsibility. Her mother has a chronic medical condition, and Silva often had to interpret interactions with doctors and medical staff. “Doing that cultural brokering and being the oldest of two,” she said, “I very early on had experiences of what it feels like to try to access services, particularly health services and insurance, not knowing the language, and being constrained by things like medical insurance.” She feels that this has made her more sensitive to the realities of some of her clients. “For me, the human connection and the development of interpersonal relationships [is] really important,” she said. After discovering a passion for psychology in high school and “sticking to it” through a master’s and a doctoral degree, Silva feels she “get[s] to combine the personal with the professional in this work. I get to work with the immigrant population and, at the same time, address mental health-related concerns that […] impact very much people’s overall wellbeing.”
The uncertainty of the pandemic only complicates many patients’ access to medical care. Because many members of the Latin American community in New Haven have low socioeconomic status, they often do not have the luxury of working from home at a socially distanced desk. “This is one more piece, one more stressor,” said Silva. “It’s clearly highlighted the disparities that exist in the system for ethnic minority communities. […] They are the essential workforce, having to go in and work.”
As disclosed by DataHaven in 2019, 94 percent of people in the Greater New Haven area have health insurance. However, for communities disproportionately suffering from mental health issues during the pandemic, having access to adequate and affordable mental health care can be extremely difficult. In 2017, Milliman, a leading consulting firm specializing in insurance and health care, released a damning reportstating that Connecticut had some of the nation’s worst disparities for affordable mental heath care access. Insurance companies denied patients’ insurance claims for mental health treatment at a higher rate than physical health treatment. Out-of-network patient visits are ten times more likely for behavioral health concerns than those for physical ones.
Sean Scanlon, Representative from the 98th district in the Connecticut General Assembly, took it upon himself to right this wrong. His landmark bill, the Mental Health Parity Act (House Bill No. 7125), went into effect in January 2020. It requires insurance companies to treat mental and physical health claims indiscriminately and to submit an annual report for accountability. Although it’s too early to say if it’s working, Scanlon said, he is optimistic because “whenever somebody is watching, people act differently.” According to him, insurance is one of the greatest reasons why people with mental illnesses do not get treatment—a trend that began in the 1960s.
When private insurance was established after World War II, said Scanlon, “the standard practice [for mental illness] was still, ‘Let’s institutionalize these people. Let’s put them in this big facility and throw away the key.’” After a wave of psychiatric deinstitutionalization in the 1960s brought about outpatient mental health care, insurance companies didn’t cover it. “Only the people who had money could afford to access that [care]. Everyone else was either becoming homeless, living in shelters, or struggling with substance use disorders because they’re using drugs to cope with the fact that they have an untreated mental illness,” Scanlon said.
These patterns of stigma and neglect deeply influenced Scanlon’s family and his professional life. “My father, who is no longer alive, struggled with alcohol addiction in his life, and I saw that up close,” he explained. “I saw that folks like my dad are often the kind of folks we like to sweep under the rug and pretend don’t exist and don’t talk about.”
When Scanlon was elected in 2014, soon after the beginning of the third wave of the opioid epidemic, he focused on reform and destigmatization. “I’ve seen addiction and understand the damage that it causes and the fact that it’s a disease and not a [moral] shortcoming,” he said. For Scanlon, mental health and substance use has always been a personal issue, “and it’s a personal issue to one in four people in [the U.S.].”
The pandemic provides a major stress test for Scanlon’s bill. The Elm City has seen over one hundred deaths related to the virus and almost three thousand more infections, but for the overwhelming majority of the population, the greatest impact on their lives will not be physical. It will be mental. “For people who have substance use disorder [or other mental health conditions] and haven’t been able to get their treatment or see their provider,” argued Scanlon, “[the added] stress of this virus or perhaps the stress of losing your job could manifest itself in a relapse.” If someone living in New Haven is dealing with mental illness and is both unemployed and uninsured,the chance of them seeing a clinician to help them cope with their trauma is often “next to none.”
It is precisely this population—unemployed and uninsured individuals—that organizations like HAVEN Free Clinic seek to serve. HAVEN is a student-run clinic that provides all of its patients with medical, legal, and social services, including behavioral health care, completely free of charge. Although it is student-run, a panel of professional advisors supervises each department to minimize patient harm and ensure that the rigorous standards are met.
“For people who have substance use disorder [or other mental health conditions] and haven’t been able to get their treatment or see their provider, the stress of this virus or perhaps the stress of losing your job could manifest itself in a relapse.”
Representative Sean Scanlon
Crystal Ruiz, a second-year Masters of Public Health candidate in Social and Behavioral Sciences at the Yale School of Public Health, is one of the co-directors of the clinic’s Behavioral Health Department, or BHD, a relatively new addition to HAVEN. “Because HAVEN serves a population predominantly made up of Spanish-speaking refugee immigrants,” remarked Ruiz,“it became clear that they were struggling with a lot of trauma, a history of traumatic events that they didn’t have any outlet for.”
It can sometimes take months to see a mental health professional, said Ruiz. But at HAVEN, people “can come in and request an appointment with us weekly, and we can see them a lot sooner. If they do require a higher level of care, then we refer them to one of our partnering institutions like the Hispanic Clinic,” Ruiz explained. BHD’s volunteer training program reflects its goal of providing more accessible care. The department is inspired by Indian psychiatrist Vikram Patel’s philosophy of making up for a dearth of mental health services by training community members as “lay practitioners” to deliver psychosocial interventions for mild mental health issues.
This commitment to community engagement is at the core of both Ruiz’s work at HAVEN and her studies at the School of Public Health. After switching from an undergraduate program in biochemistry to one in medical anthropology, she was “exposed to a lot of the intersectionality that is present in health care,” which encouraged her to learn about “why certain immigrant and refugee communities develop, not necessarily mental disorders, but adopt behaviors that create opportunities for harm.”
Her academic interests, along with a desire to find community within a school that does too little for the underserved populations in New Haven, drew her to HAVEN. In a city where 44 percent of Latinos either received postponed care or no care at all for a health condition in 2018, Ruiz is disappointed that she always sees the impetus coming from students. Given that Yale is a predominantly white institution, however, she is not surprised. “It was just weird being presented with a really amazing opportunity—studying at the School of Public Health—but then not being able to contribute anything to the community.” Considering the amount of physical and economic resources that Yale takes from New Haven, Ruiz wanted to find a way to give back, and one of those outlets was through HAVEN. “I thought it was great because our main population is Spanish-speaking. They’re usually Latinx [community] members, and that’s […] my community, who I identify with. Being able to provide direct care to people in my community makes me feel like I’m back at home.”
Insurance and a shortage of mental health services aren’t the only limiting factors to accessing care, however. Many living in low-income communities, Silva mentioned, also have unequal or sparse access to technology, which is especially harmful during a pandemic when mental health care has gone virtual. “Challenges include whether our patients even have access to WiFi,” Ruiz started, “if they have a phone that has the capacity to support Zoom or support video conferencing, if they have unlimited versus limited minutes, if they have access to a quiet space to discuss some of their personal medical concerns.”
Both Silva and Ruiz supervised a transition to telehealth due to the ongoing pandemic. While HAVEN’s IT team was able to quickly set up HIPAA-compliant communications systems for the clinic as soon as Governor Lamont hinted that clinics would have to close, virtual health care presents a new set of problems. “It’s very hard to see certain signs and symptoms via a laptop or a phone screen,” Ruiz said. Some changes in therapy have been more prominent. Silva recalls that, in recent sessions, “a lot of our time was spent on just checking in on people coping with COVID: Do they physically have any symptoms? [Are they] social distancing, mask wearing, [following] all the precautions? […] We’re still trying to find the balance between that piece plus their ongoing treatment goals.”
Stigma surrounding mental health, especially in Hispanic immigrant communities, poses a significant challenge to providing effective virtual care through the Behavioral Health Department. State-mandated isolation and social distancing measures mean patients spend more time at home with their families, which makes talking about mental health issues more complicated. In Silva’s practice, many patients “enjoy coming to treatment and leaving their homes because a lot of their stress is related to their home environment.” The privacy and freedom to talk in the office is no longer there, which limits how much progress patients make on their treatment plans. At HAVEN, this manifests itself in limited responses on the questionnaires used to screen for symptoms of psychopathology: “There are some things you don’t feel comfortable saying around other individuals,” Ruiz mentioned. “Much of the time when they’re answering our questionnaires, they’ll limit their responses to yes, no, yes, no […]. They don’t feel very comfortable with elaborating and providing further information.” Ruiz sounded tired over Zoom. After a long day of classes, coordinating BHD meetings, and participating in clinic-wide subcommittees for research and departmental enhancement projects, she understood that her clients were likely also overworked and still trying to adapt to the new telehealth system.
Despite the uncertainty New Haven is wading through, the city has slowly come back to life. Over the summer, a socially distant Wooster Square Farmers’ Market reopened, and medical students handing out surgical masks joined the protests against anti-Black police violence. At the Hispanic Clinic, Silva’s team modified an in-person group program with twice-a-week, three-hour meetings for Zoom. “Once we were able to use Zoom to get the group going again, they advocated for stuff like more time and more frequent meetings,” said Silva. “There were definitely some bumps along the way, […] but once they got connected, they absolutely loved it.” No matter the circumstances, people need to feel connected to each other. For Silva, there was a clear lesson learned: “Even if there is some discomfort in the process—like the technology piece—they’re willing to put up with that, to follow through with their treatment.”
Humans are naturally social creatures, but the pandemic has shown that they are adaptable, too. However, as the pandemic continues to rage throughout the country, mental health will not just be a priority—for many, it will become a necessity for survival.
In the aftermath of the 1918 Spanish influenza pandemic, survivors experienced significant increases in sleeping disturbances, depression, and trouble coping with everyday life for years after the pandemic’s end, Norwegian historical demographer Svenn-Erik Mamelund conservatively noted in 2003. Psychiatric hospitalizations also saw an unexpected rise in first-time patient admissions in the following years. If past pandemic responses have any bearing on the future, current epidemiological trends show cause for concern. “Anxiety is way up, depression is way up, suicidal thoughts are way up, [and] using is way up,” said Scanlon. While it’s too soon to understand how much COVID-19 will affect mental health, one thing Scanlon knows for certain is that the psychological ramifications of the pandemic will persist well after we have a vaccine.
—Nicholas Ruiz-Huidobro Magdits is a senior in Trumbull College and an Associate Editor.