This City Is Killing Me. Jonathan Foiles

rather than SSDI.

      The maximum amount you can get for SSI is determined by the Federal Benefit Rate (FBR), which is calculated annually. For 2019, the FBR is $771 for an individual and $1,157 for a couple. Some states kick in some extra money beyond the federal limit, but the amount is usually insignificant. Keep in mind that that figure represents the maximum you can receive; if you receive any other form of income (which includes someone providing you with food or housing), the amount you get is deducted from the FBR. There is also a limit on resources, meaning that you cannot have more than $2,000 as an individual or $3,000 as a couple at any time to continue to be eligible for benefits.

      When you first apply for disability, you mail in all of your materials and wait several months for someone to examine them and decide whether or not you are eligible. Most people are rejected at this stage; out of all of the patients I’ve treated as they went through the process, only one of them was approved on their first try. If you are denied, you have about two months to appeal. If you appeal, your case will linger for another several months until someone else takes a look at your paperwork. If they also deem you ineligible, you can appeal one more time and ask for a trial. That’s assuming you make it that far; some give up and, according to a 2017 report from the Washington Post, 10,000 people died in fiscal year 2017 while waiting for a final decision.⁸ At the end of this process, beneficiaries are only eligible for a maximum of $9,252 per year for an individual, $13,884 for a married couple. To put this in context, the latter figure is only 23 percent of the median U.S. household income ($61,372 as of September 2018). Receiving SSI can be a lifeline for many of my patients, but it also guarantees that they will continue living below the poverty line and prevents them from saving even small amounts to try to better themselves.

      The average rent for a studio apartment in the cheapest neighborhood in the city (which also means one of the most dangerous neighborhoods) is $612. Even if Jacqueline could find an apartment below that rate, she would have little money left over for even the bare essentials. She would like to begin the process to officially change her gender and legal name, but that also takes money. If forced to choose between food and electricity or correcting her identification, she will, like most people, choose the former rather than the latter. Chicago House, a LGBTQ non-profit formed in the wake of the AIDS crisis, has developed a program to aid the at-risk trans population, and many of them are in the same boat as Jacqueline. Only 21 percent have been able to update all of their identification to conform to their correct name and gender identity. Transgender people experience homelessness at twice the rate of the general population. Most trans individuals experiencing homelessness at the very least experience harassment; 29 percent are turned away from homeless shelters and 22 percent are sexually assaulted there if they manage to get in.⁹

      Contemporary society often pushes those who do not fit into its conventional boundaries into false selves, a concept first explored by British pediatrician Donald Winnicott in his 1960 book The Maturational Process and the Facilitating Environment. Inspired by Freud’s The Interpretation of Dreams, Winnicott was the first pediatrician in the United Kingdom to complete psychoanalytic training. He became involved with the effort to evacuate children from major cities to the countryside in the midst of World War II. Winnicott was struck by how devastating the move could be on young children, and for most of the rest of his career he was interested in how the infant develops into a child and eventually an adult. He attached profound significance to the early events of one’s life; even if one was no longer consciously aware of them, he believed that they continued to exert influence over the way one relates to others and forms relationships well into adulthood.

      The pressure families and societies exert to ensure conformity at an early age has a similar effect on the psyche. One may be pushed to speak and write in a language that is not one’s own, be pressured to regard cultural practices and traditions as ‘odd’ or ‘un-American,” be forced to sublimate essential elements of one’s personality to fit in. As Winnicott notes, we all do this to some degree; the language that I use with my patients is not the language I use with my friends or my wife. I’m aware of this disparity, though, and can switch easily between personalities with opprobrium. Many others like Jacqueline don’t have it so easy.

      Jacqueline was the first patient who made me think about Winnicott’s true and false selves. She took to describing her symptoms as the battle between “Jason”—her old masculine self who was angry, prone to self-harm, and desperately unhappy—and “Jacqueline”—her true feminine identity who was kind, happy, and loving. Right now she saw herself as in-between, an identity she called “Jackie.” Her internal mood would shift between the personalities depending upon how she was feeling at any given time. Jacqueline wanted to make it clear that she did not think she actually had multiple personalities, and indeed she demonstrated no signs of dissociative identity disorder (what used to be called multiple personality disorder). Rather, she felt pressure to be a false version of herself, and it took work to resist that pressure.

      One of Jacqueline’s first false selves was a straight teenager. She had even gotten a past girlfriend pregnant when they were in high school, and although she did not regret the abortion that followed, she felt some regret that she had never become a parent. She then shifted into a gay male false self, slightly more comfortable but ultimately unsatisfying. It wasn’t until she finally became a transgender woman that she could begin to feel like herself, but this was not nearly as easy as it may sound.

      Jacqueline heard voices inside her head, and they were cruel. They told her that she was not really a woman but a man, that God hated her, that she was disgusting. On one level these are psychotic symptoms, a manifestation of her mental illness. At the same time, they were also an internalization of the pressures to maintain her false self. Her illness may have provided the form of her psychosis, but culture provided its contents.

      To be clear, several communities and institutions have let Jacqueline down, but if she had had access to good, affirming, and consistent mental health care, things could have been very different. Instead of receiving such services, her reliance upon the social safety net often forced her to migrate from clinic to clinic. Instead of a comprehensive diagnosis that would take stock of the variety of societal pressures that helped create her suffering, she was affixed with a label that blamed it all on her. Instead of being treated humanely, she was written off as just another dramatic and manipulative borderline.

      Jacqueline’s discomfort with her true self meant that she found it very hard to be alone. She had lived by herself earlier in her twenties, but when her symptoms worsened she moved back in with her mother. Due to her frequent suicide attempts, she was on virtual lockdown inside her home. Her mother removed the doors from her bedroom and the bathroom. She had to ask her mother for a knife to cut her food or a razor to shave. I could sympathize with her mother’s caution to a degree. Jacqueline could be quite impulsive, and I also feared what she could do with little forethought. At the same time, however, that’s not much of a way to live.