Mental Health and Poverty in the Inner City

Mental Health and Poverty in the Inner CityUjunwa Anakwenze anri Daniyal Zuberi

Rapid urbanization globally threatens to increase the risk to mental health and requires arethinking of the relationship between urban poverty and mental health. The aim of thisarticle is to reveal the cyclic nature of this relationship: Concentrated urban poverty culti-vates mental ulness, while the resulting mental illness reinforces poverty. The authors usedtheories about social disorganization and crime to explore the mechanisms through whichthe urban environment can contribute to mental health problems. They present some dataon crime, substance abuse, and social control to support their claim that mental ulness rein-forces poverty. The authors argue that, to interrupt this cycle and improve outcomes, socialworkers and policymakers must work together to implement a comprehensive mentalhealth care system that emphasizes prevention, reaches young people, crosses traditionalhealth care provision boundaries, and involves the entire community to break this cycle andimprove the outcomes of those living in urban poverty.

KEYWORDS; health and environment; health promotion; mental health; social policy; urban health

G lobally, the number of people who residein cities is rapidly increasing. In 2007,more than half the world's populationlived in urban areas, and steady increases were pro-jected for future decades (Freudenberg, Galea, &Vlahov, 2006). Scholars have observed that "someof the best-established effects of urbanization con-cern mental health" (Lederbogen et al., 2011,p. 498). Meta-analyses provide evidence that thosewho live in cities have a higher risk for mood dis-orders, anxiety disorders, and schizophrenia(Lederbogen et al., 2011). At some point in theirlives, 46 percent of Americans wiU experience atleast one disorder listed in the DSM-IV (Kessleret al., 2005). The conceptual firamework for thisarticle is based on a pragmatist view of the relation-ship between social structure and outcomes andthe importance of evidence-based policy and pro-gram reform to address urban social problems.

The relationship between mental health andurbanization is complex. Traditionally, some scholarshave pointed to the role of the urban physical envi-ronment. Exposure to noise and lack of adequategreen spacekey features of the urban environ-mentcan cause psychological distress, hyperten-sion, and hearing impairment (Chang, Jain, Wang,& Chan, 2003; Freudenberg et al., 2006). Mentalhealth problems are disproportionately manifestedamong the urban poor. The poverty that is charac-teristic of certain areas in the urban environmentnot only contributes to the prevalence of mental

illness but also is created and entrenched by mentalillness. We argue that the relationship betweenmental health and the urban environment is notlinear but cyclical and reinforcing. The poverty ofthe urban environment cultivates mental illness,while the resulting mental illness reinforces urbanpoverty. To interrupt this cycle, social workers andpolicymakers must implement a comprehensivemental health care system that emphasizes preven-tion, reaches young people, crosses traditionalhealth care provision boundaries, and involves theentire community.

In this article, we use theories about social disor-ganization and crime to explore the mechanismsthrough which the urban environment contributesto or harms an individual's mental health. Thenwe use information about crime, substance abuse,and social control to support our claim that mentalillness reinforces poverty. As a response to thebidirectional relationship between mental healthand urban poverty, we recommend a series ofmental health interventions that mobilize a varietyof institutions and individuals within the commu-nity to promote improvements in mental health.

URBANIZATION, POVERTY, AND MENTALHEALTHDifferent mechanisms are important for explainingthe relationship between city living and mentalhealth disorders. Among these are socioeconomicdisparides (Wilkinson & Pickett, 2010), poverty

doi: 10.1093/hsw/hlt013 2013 National Association of Social Workers 147

(Belle, 1990), the presence of residentiaUy unstablepopulations, dense and diverse populations, highcrime rates, and social disorganization (Freuden-berg et al., 2006). Each of these subjects city dwell-ers to substantial stress. For example, spatialsegregation along racial, ethnic, or socioeconomicHnes reinforces poverty for low-income residents.The forced homogeneity of these social networkties often precludes spatial proximity of poor urbanyouths to edifying role models. Yet socioeconomi-caUy disadvantaged people require more diversesocial ties to improve their socioeconomic status(SES). Segregation is also unfortunate because itdoes not allow the formation of social networksthat would result in employment or social mobility(Freudenberg et al., 2006). Many ofthe risk factorsdiscussed may be cumulative, increasing vulnera-bility to mental health issues among low-incomeinner-city children and youths (Evans, 2004).

Joblessness and UnderemploymentIn When Work Disappears, William Julius Wilson(1997) made a connection between urban povertyand mental health when he asserted that unstablework and low income decrease one's perceivedself-efficacy. A recent meta-analysis found thatindebtedness is one mediating factor between pov-erty and poor mental health (Fitch, Hamilton, Bas-sett, & Davey, 2011). Another study completed inPhiladelphia supported these findings by revealingthe adverse effects of economic pressure on mentalhealth and parental behavior, based on a sample ofblack and white inner-city parents (Elder, Eccles,Ardelt, & Lord, 1995). The researcb revealed thatmounting economic pressures, caused by unstablework and low income, created feelings of emo-tional distress and, as a result, tended to lower theparents' sense of efficacy regarding what theybelieved to be their influence over their childrenand their children's environment. Perceived inef-fectiveness was particularly magnified among Afri-can American families, single-parent households,and conflicted marriages, undermining parentwell-being. Particularly among African Americanfamilies, a sense of parental self-efficacy is predic-tive of child management strategies that enhancedevelopmental opportunities for children and min-imize behavioral risks (Elder et al., 1995). Thismeans that financial stability can play an importantrole in detennining a child's mental health. Differ-ent neighborhood characteristics can support

mental health resilience or negative outcomes(Wandersman & Nation, 1998).

Neighborhood DisorderThe extent of an individual's perceptions of neigh-borhood disorder has also been found to signifi-cantly affect levels of mental distress (McKenzie SiHarpham, 2006). In a 2003 study, researchersexamined the relationship between perceptions ofone's neighborhood, levels of social support andsocial integration, and level of subsequent depres-sive symptoms among 818 individuals screened foran HIV prevention intervention, most of whomwere current or former drug users. Data from afollow-up interview nine months after the inter-vention illustrated that negative perceptions ofneighborhood characteristics (including drug sales,litter, vacant housing, teenagers loitering, and rob-bery) predicted depressive symptoms.

The Epidemiologie Catchment Area Study, thelargest community mental health survey ever con-ducted in the United States, corroborated thesefindings in a study of 20,000 adults in five commu-nities, to estimate the prevalence and incidence ofspecific psychiatric disorders in a sample of institu-tionalized and noninstitutionalized individuals.The study reported that there is an inverse relation-ship between socioeconomic position and psychi-atric disorders (Yu & Williams, 1999). The datasupport tbe theory of social disorganization andhint at the need for a broad structural intervention.As neighborhood disorder is a powerful chronicStressor, it may even be possible to identify entireneighborhoods in which all residents are at an ele-vated risk for depression (Latkin & Cuny, 2003).

The mechanism that explains the link betweenperceived neighborhood disorder and mental well-being is a complex one with important implica-tions. Neighborhoods with high levels of disorderindicate to residents, by means of visible signs andcues, a lack of social control. While some residentsdo not respect property or their neighbors, tradi-tional agents of control are unwilling or unable tocope with local problems. At worst, the neighbor-hood has been abandoned, and its inhabitants mustfend for themselves (Hill, Ross, & Angel, 2005).

Disorder is a signal of perceived threat. An envi-ronment in which residents report muggings,assaults, gangs, drug use, inadequate police protec-tion, unsupervised youths, and other forms ofsocial disorder may undennine physical health by

148 Health & Social Work VOLUME 38, NUMBER 3 AUGUST 2013

several pathways, including a psycho-physiologicalstress response (Hl et al,, 2005). Such physiologi-cal responses may be experienced as rapid heart-beat, trouble breathing, upset stomach, sweating,dry mouth, and numbness or tingling in one'slimbs (Hill et al,, 2005), Hill et al, supportedthis model using data from the Welfare, Children,& Families: A Three City Study, which studied2,402 women in disadvantaged neighborhoods inChicago, Boston, and San Antonio, The studyconcluded that psychological and physiologicalstress responses to ongoing danger, dilapidation,drugs, and neglect in a neighborhood mediate theassociation between neighborhood disorder andhealth.

The same data were also used to show that resi-dents of disadvantaged neighborhoods drink moreheavily than residents of more affluent neighbor-hoods (Hl & Angel, 2005), Again, perceptions ofneighborhood disorder were shown to often resultin the development of mental health conditionsin this case, heavy drinking and addiction. Thestress of living in a neighborhood characterized bydrug abuse, crime, unemployment, abandonedhouses, teenage pregnancy, idle youths, and unre-sponsive police can be psychologically distressingand lead some people to consume alcohol in hopesof alleviating feelings of anxiety and depression(Hill & Angel, 2005), Hill and Angel found thatthe positive association between neighborhooddisorder and heavy drinking is largely mediated byanxiety and depression, thereby demonstrating thatthe stress of living amid concentrated urban pov-erty can lead to further manifestations of mentalhealth problems, HiU et al. (2005) noted that thedisadvantaged get stuck in disadvantaged neigh-borhoods with few routes of escape and are thusthe most susceptible to the mental illness thatresults firom neighborhood disorder. This vulnera-bility is exacerbated by the fact that low-incomeyouths have greater access to alcohol than doyouths in middle-income neighborhoods (Levan-thal & Brooks-Gunn, 2000),

CHILDREN'S MENTAL HEALTH AND POVERTYThe impact of poverty and social disadvantage onchildren's health is flirther evidence that poverty isa serious risk factor for mental illness. Low-incomechildren disproportionately suffer from deficits incognitive skills and educational achievement (Har-ding, 2010; Murali & Oyebode, 2004). Hunger

increases risks to health and mental health (Wein-reb et al., 2002). Behavioral problems, such asattention deficit/hyperactivity disorder, are alsolinked with family poverty. They are most pro-nounced among children whose families face per-sistent economic stress (Murali & Oyebode, 2004).Poverty can cause stress and result in depression inchildren because stressful social environments affectthe biology of the brain in ways that can becomeserious if Iefi: untreated (Hernandez, Montana, &Clarke, 2010). Economic insecurity can also affectthe mental health of parents, causing anxiety, psy-chological distress, and depression. These mentaldispositions influence their interactions with theirchildren, thereby influencing their children's men-tal health (Hernandez et al,, 2010).

Mediating Role of Crime and InsecurityCrime is also a major component of poverty in theurban environment that mediates a relationshipbetween city living and mental illness. Isolated epi-sodes of violence coupled with chronic exposureto violence can prompt a variety of emotional reac-tions from adults and children alike. Many of theseare symptoms of posttraumatic stress disorder(PTSD) (Marans et al., 1995). Research suggeststhat urban poverty contributes to mental illness.For example, in the Moving to Opportunity(MTO) housing mobility experiment, publichousing residents in five cities were randomlyassigned to a control group and two treatmentgroups, one that was given rent vouchers thatcould be used only in low-poverty neighborhoods(defined as less than 10 percent poverty) and onethat received unrestricted vouchers (Harding,2010). The researchers assessed the effects of therent vouchers by examining the neighborhoodsinto which famihes in the treatment groups movedand outcomes such as health, education, employ-ment, and criminal behavior. Some important dif-ferences were detected between the treatmentgroups and control group at the evaluations thattook place five to seven years later. The differencesfound were primarily related to mental health,stress, and safety; these differences favored youthswho moved to low- to middle-income neighbor-hoods rather than those who remained in publichousing in poor neighborhoods (Harding, 2010).A rvaluation of the MTO data found that girls infamihes who remained in low-income neighbor-hoods for longer periods had better mental health

ANAKWENZE AND ZUBERI / Mental Health and Poverty in the Inner City 149

(and engaged in fewer) risky behaviors than thecontrol group (Leventhal & Dupr, 2011). Inanother study involving a nonrepresentative sampleof New York City high school youths, exposure toviolence was significantly related to a higher inci-dence of depression and hostility (Moses, 1999).

A review of research on the effects of neighbor-hood residence on child and adolescent well-beingfound that a number of national and regional stud-ies suggest that residing in neighborhoods of lowSES is associated with higher rates of criminal anddelinquent behaviors. This review also cited theYonkers Project, in which adolescents whoremained in low-income neighborhoods weremore likely to show signs of problem drinking andmarijuana use than youths who moved tomiddle-income neighborhoods (Levanthal &Brooks-Gunn, 2000). Another study found thatyouths in low-SES neighborhoods perceivedgreater danger than their peers in high-SES neigh-borhoods and that this perception negatively influ-enced their mental health. Low-SES children andchildren from single-parent families were mostlikely to be exposed to aggressive peers in theneighborhood (Levanthal & Brooks-Gunn, 2000).

Several quantitative studies have reported thatthe quantity and behavior of one's peers bothmediate and moderate neighborhood effects(Levanthal & Brooks-Gunn, 2000). In socially dis-advantaged neighborhoods, fewer informal andfomial social networks exist for youths, which maybe associated with delinquency, problem behavior,prosocial competence, and negative peer groupaffiliation. Peer deviance, often in the fonn of vio-lence, mediates the negative effect of neighbor-hood disadvantage in adolescents' mental health(Levanthal & Brooks-Gunn, 2000).

EfficacyThe potential for exposure to violence to result inmental health outcomes such as PTSD and depres-sion is likely linked to the increasing perceptions ofpowerlessness and feelings of diminishing self-efficacy that are caused by violence and neighbor-hood di.sorder. Research has shown that, at theindividual level, higher SES directly promotes asense of efficacy, control, and even biologicalhealth. It is possible that, at the community level,the alienation, dependency, and exploitationcaused by resource deprivation inhibit collective

efficacy, which is social cohesion among neighborsand their willingness to intervene for the publicgood (Sampson, Raudenbush, & Earls, 1997).Sampson and colleagues presented the theoreticalunderpinnings to explain how racial and economicexclusion influence perceived powerlessness andmental health in disadvantaged neighborhoods.They also explained that collective efficacy medi-ates much of the association of residential stabilityand disadvantage with multiple measures of vio-lence (Sampson, Raudenbush, & Earls, 1997).Individuals who feel powerless are unlikely tointervene in an effort to reduce violence in theneighborhood.

CONSEQUENCES OF URBAN VIOLENCE ANDVICTIMIZATIONEniotional responses to violence among individualsin disadvantaged neighborhoods can take on anumber of different fomis. Repeated exposure toviolence may lead to persistent patterns of psycho-logical withdrawal, depression, and social disen-gagement (Marans et al., 1995). Based on hisresearch on boys in low-income Boston communi-ties, Harding (2010) argued that there is a physio-logical mechanism by which the prevalence ofviolence within disadvantaged neighborhoodsyields serious mental health problems, as chronicstress results in biological responses that undermineself-efficacy:

Long-term experience of chronic stress createdby exposure to violence and threat of victimiza-tion can have physiological consequences. . .[and] can influence cognitive functioningby inhibiting the formation of connectionsbetween neurons in the brain and by impairingmemory.. . . [It] can also lead to greater aggres-siveness, impulsivity, anger, and susceptibility tosubstance use.. . . These biosocial consequencesof violencepoor cognitive development, risktaking, and substance usemay in tum increasethe risk of school dropout or teenage pregnancy.(Harding, 2010, p. 281)

The threat of violence, when combined with job-lessness, substandard housing, and inadequateschooling, causes individuals to develop evenstronger feehngs of powerlessness (Marans et al.,1995).


PTSDThe psychological distress caused by trauma andviolence in areas of concentrated urban povertyoften takes the fonn of PTSD. Therefore, it isessential that any thorough analysis of mentalhealth in the inner city address this disorder. PTSDprevalence is 9 percent to 12 percent in the generalpopulation, but it is most likely higher among resi-dents of urban, economically disadvantaged areasbecause this population is at higher risk than thegeneral population of exposure to traumatic events(Schwartz, Bradley, Sexton, Sherry, & Ressler,2005). There is a greater risk of victimizationamong inner-city residents because of low SES andhigh rates of violence. Therefore, trauma is oftenunderrecognized, and PTSD is often under-diagnosed (Schwartz et al, 2005). This is especiallydetrimental in light of findings firom a study thatexamined African American outpatients in aninner-city mental health clinic. The study reportedthat individuals with PTSD are more likely to haveworse clinical and quality-of-life characteristics,such as nonschizophrenic psychosis and depression(Schwartz et al., 2005). PTSD was also associatedwith high rates of suicide attempts and comorbidsubstance use and depression (Schwartz et al.,2005; Valera, Sawyer, & Schiraldi, 2001). Thestudy suggested that the extent of previous traumais significantly correlated with PTSD symptomseverity (Schwartz et al., 2005).

These findings are supported by another studyinvolving women recruited from two obstetrical-gynecological clinics serving low-income womenin a midsize midwestem city. Most participantswere African American, in their early 20s, single,unemployed, and had one child (Schumm, Briggs-Phillips, & Hobfoll, 2006). The study demonstratedthat effects of interpersonal trauma are cumulativesuch that women who experienced either childabuse or adult rape were six times more likely tohave PTSD, whereas women who experiencedboth child abuse and rape were 17 times more likelyto have PTSD (Schumm et al., 2006). Anotherstudy examined reported levels of violence andassessed the existence of PTSD among 100 female,male, and transgender male prostitutes in inner-cityWashington, DC (Valera et al, 2001). During theirinvolvement with prostitution, over 60 percent ofthe participants had experienced violence and 44percent had been raped; 42 percent met establishedcriteria for PTSD.

Responses to TraumaStreet sex workers who are exposed to violent actsalmost every day are at an even greater risk thanthe general public for psychological distress (Valeraet al., 2001). Thus, there is a need to acknowledgethe presence and influence of PTSD when design-ing and implementing interventions for them. Thesame can be said for AiHcan Americans and otherpredominantly low-income groups in response toother studies that have focused on PTSD in theinner city.

These findings constitute a major urban socialproblem because they suggest that trauma is acommon experience for low-income residentsof the inner city. Social workers and other pra-ctitioners should acknowledge the extent andsignificance of PTSD and the accompanying com-plications that might impede successflil inter-ventions. For example, avoidance, one of thesymptoms of PTSD, can lead to avoidance ofemotional ties with social workers and other prac-titioners trying to assist clients with PTSD (Valeraet al., 2001). Policymakers must also invest greaterresources in improving inner-city mental healthservices and supports.

POVERTY AND MENTAL HEALTH:A BIDIRECTIONAL RELATIONSHIPThe relationship between SES and mental health isbidirectional, with poverty often leading to mentalillness and mental illness regularly reinforcing pov-erty. The criminal justice system exemplifies thisrelationship. A high percentage of the mentally illare arrested, and this perpetuates poverty for thosewithin that population. Incarceration reduces thepotential for future employment (Clark, Ricketts,& McHugo, 1999; Pager, 2007). Longitudinal sur-vey data on a cohort of young men suggest thatyouth incarceration is associated with a 25 percentto 30 percent decUne in the average number ofweeks worked annually. Although a third of thisdecline can be attributed to recidivism, a substantialportion of it is associated with the far-reachingeffects of incarceration (Pager, 2007). Anotherstudy found that youth incarceration reducesemployment by more than 5 percent, with effectsthat continue even 10 to 15 years after incarcera-tion (Pager, 2007). The role of incarceration intrapping individuals in poverty has especiallyimportant implications for mentally iU individualsliving in the inner city.


AddictionMany people who are arrested struggle with addic-tion. Clark et al. (1999) followed individuals withco-occurring severe mental illness and substanceabuse disorders for three years to better understandvarious aspects of their involvement with the legalsystem. Their findings indicated that effective treat-ment of substance abuse among individuals withmental illness reduces incarcerations and arrests,supporting the bidirectional model of the poverty-mental health relationship (Clark et al., 1999).

Depression and AggressionSymptoms of mental disorders can also increase therisk of impulsive and aggressive behaviors amongadolescents. Research on young delinquent popu-lations has demonstrated that youths with mentaldisorders are at greater risk of engaging in behaviorsthat result in entanglement with the juvenile jus-tice system (Grisso, 2004). Depression is associatedwith adolescent aggression; previous exposure toviolence and victimization, which is common inlow-income urban settings, was the strongest pre-dictor of an adolescent's own violent behaviors(Moses, 1999).

Systemic FailureDeficiencies in the child and youth mental healthsystem appear to be responsible for bringingmany youths with mental disorders into the juve-nile justice system. Two-thirds of youths in thejuvenile justice system meet the criteria for one ormore mental disorders. The prevalence of youngpeople with mental health problems in the juvenilejustice system indicates that mental illness, throughinvolvement in crime, predisposes many teenswith mental disorders to low occupational achieve-ment and SES (Grisso, 2004). Adolescents in low-income urban neighborhoods who suffer frommental illness may also be headed toward povertyby means of a complex biosocial pathway in whichexposure to violence causes them to experienceslowed cognitive development, poor academicachievement, and difficulty in forming relation-ships. These are all risk factors for high schooldropout and subsequent poverty during adulthood(Harding, 2010).

MENTAL HEALTH AND URBAN POVERTYBecause of the bidirectional relationship betweenmental health and urban conditions (primarily

crime and poverty), it is most accurate to describethis relationship as cyclic. This cyclic relationshipcan be seen in low-income children who areexposed to violence in an urban neighborhoodand experience psychological distress as a result ofthe trauma. Clearly, living in urban poverty influ-ences their mental health. Over time, they arelikely to become involved in delinquent and vio-lent activities as a means of organizing their senseof self (Marans et al., 1995). Traumatic stresscaused by exposure to violence can harm egodevelopment, foster impaired identity formation,and result in low self-esteem. Identity can becomedistorted to embody criminality and violencebecause these children and adolescents perceivethese as markers of adulthood (Moses, 1999).Moses (1999) argued that "it is widely acceptedthat personal characteristics such as gender influ-ence risk-taking behaviors, exposure to violence,and the manner in which individuals respond totraumatic stress" (p. 22). Although boys and menhave a greater likelihood of being exposed toneighborhood violence, girls and women aremore likely to demonstrate increased symptoms ofdepression and hostility (Moses, 1999). By engag-ing in violent activities that are typical of theirsurroundings, children and adolescents reinforcethe nature of the urban environment and maylimit their opportunities for formal employmentas a result of incarceration and criminal records(Marans et al., 1995). Thus, the relationshipbetween mental health and urban poverty comesfull circle.

This circularity is also embedded in the socialdisorganization mechanism. High levels of socialorganization within communities usually protectresidents against stress and illness (McKenzie &Harpham, 2006). However, most inner-cityneighborhoods have relatively low levels of socialorganization, as exemplified by a lack of fonnalorganizations, resource-poor social networks, lowlevels of responsibihty for community issues, andminimal involvement in community organiza-tions (McKenzie & Harpham, 2006). Ukimately,social disorganization reinforces poverty and fur-ther disorganization. In U.S. cities, low-incomeresidents, who endure the most exposure to Stress-ors and experience a greater need for mentalhealth resources, have less access to treatment thantheir wealthier counterparts (Freudenberg et al.,2006).


ADDRESSING THE CHALLENGE: COMMUNITYMENTAL HEALTH CARE COALITIONSIn light ofthe complex relationship between men-tal health and urban poverty, cities need a compre-hensive mental health care system that willinterrupt the povertymental health relationship. Insuch a system, partnerships can be developedbetween "parents, agencies, and institutions andfederal, state, and local systems to meet needs ofthese children and their families" (Marans et al.,1995, p. 9). It must also be centered on the com-munity. Social workers can and should play animportant role advocating for and building coali-tions to generate pressure and political will to createand implement these community-based programs.

A strong, comprehensive mental health care sys-tem should also emphasize child and adolescentmental health. It is also important to include youngpeople in well-planned, school-based mental bealthinterventions (Marans et al., 1995). The new sys-tem should break down traditional boundaries inhealth care provision and involve parents and thecommunity in identifying children who are at highrisk of mental health issues and providing treatment(Marans et al., 1995). For example, instead of rely-ing exclusively on mental health professionals,social workers should help train teachers, policeofficers, coaches, and pastors to serve as allies. Aspartners witb mental health professionals, socialworkers and other practitioners should be an inte-gral part ofthe effort to interrupt the cycle of pov-erty and mental health (Marans et al, 1995). Theseprograms should address risks and improve resil-iency (Doll & Lyon, 1998).

Reducing Barriers to AccessIn the inner city, there is a clear need not only formental health care, but also for reducing barriers toaccess. Two-thirds of children who need mentalhealth services are never connected with them(Brauner & Stevens, 2006). Urban minority chil-dren are at high risk for the development of a widerange of mental health problems but are the leastlikely to come in contact with service providers orreceive relevant interventions (McKay, Nudelman,McCadam, & Gonzales, 1996). Among those whodo meet with a service provider, the most vulnera-ble children, in terms of seriousness of mental ill-ness or complexity of social situation, are the leastlikely to return after an initial mental health caresession (McKay, Nudelman, et al., 1996).

Evidence-Based ApproachesEmpirical findings can provide a strong basis forrestructuring urban child mental health servicedelivery systems. Research has demonstrated thatone key strategy in overcoming barriers to access istraining urban service providers to engage familiesin child mental health services. In this context,engagement refers to the process in which a child isidentified as experiencing mental health problemsand then receives appropriate and sufficient mentalhealth care (McKay & Bannon, 2004). It is criticalthat social work educators assist social workers indeveloping "focused, culturally sensitive engage-ment skills that address the range of barriers thatcan exist within families, urban environments, andagencies interfering with the process of engage-ment" (McKay, Nudelman, et al., 1996, p. 463).The family associate engagement strategy, forexample, was designed to provide customized out-reach and support to low-income families witbchildren in need of mental health care (McKay &Bannon, 2004). Family associates were trained toencourage such families to connect their childrenwith mental health resources and to continue withthe recommended services. They provided familieswith emotional support, information, and help inovercoming specific barriers, such as the inabilityto access child care or transportation. This strategywas effective in promoting continued contactbetween families and the child mental health ser-vice delivery system. McKay, Lynn, and Bannon(2005) also found strong evidence that intensiveengagement strategies employed during initialcontacts with children and their families can sub-stantially increase use of services. Social workersshould reach out to and work with families toovercome barriers to youths receiving mentalhealth care.

Overcoming Mistrust: Care AlliancesOne explanation for the large gap between mentalhealth care need and treatment participation inimpoverished urban communities is that there is amistrust of outsiders, including many ofthe peopleproviding mental health care or conductingresearch (McKay & Bannon, 2004). To close thegap and maximize use of mental bealth resourcesin these communities, collaborative research effortsbetween researchers and clients may help to createalliances and increase the relevance of services.These alliances may create a better understanding


of the challenges families face and how difficultiesrelated to engaging families in services may beaddressed (Harrison, McKay, & Bannon, 2004;McKay & Bannon, 2004). It is essential that childmental health agencies and providers considerinput from families when evaluating service deliv-ery options or targeting specific barrien to care.Social workers should foster linkages between ser-vice providers and clients in collaborative researchefforts and use the data to improve the effectivenessof services.

School-Based ServicesSchool-based health centers (SBHCs) are anotheressential component of the kind of comprehensivesystem that is needed to overcome the structuralbarriei-s present in areas of urban poverty. Becauseabout half of Americans will meet the criteria for aDSM-IV disorder sometime in their lives, withinitial onset usually during childhood or adoles-cence, interventions aimed at prevention or earlytreatment should be focused on youths (Kessleret al, 2005).

SBHCs facilitate access to preventive health ser-vices and educate young people about activitiesand behaviors that promote well-being. Extendingthe services of SBHCs to parents and caregiverscould increase the accessibility and availability ofschool programs for the broader community.Schools are an ideal venue for selective or universalinterventions (Black & Ktishnakumar, 1998).SBHCs are also more accessible to students thantraditional community mental health servicesbecause they decrease stigma, support more com-prehensive services, and increase efficiency by pro-viding services at a location in which students areavailable (Rappaport, 2001).

SBHCs also have the potential to address teach-ers' limitations in dealing with mental health issuesin the classroom. In a recent study, teachers fromsix elementary schools in a major midwestem citywere surveyed about their feelings regarding men-tal health service needs in inner-city elementaryschools. Half of the teachers reported disruptivebehavior as the largest mental health problem attheir schools and identified a lack of informationor training as the greatest obstacle to overcomingmental health problems. Although most of theteachers surveyed had taught students with mentalhealth problems at some point, most had had littlemental health education and minimal consultation

with mental health professionals. As a result, theteachers' knowledge of these issues was inadequate,and they were not confident about their capacityto deal with them (Walter, Gouze, & Lim, 2006).

An intelligently conceived SBHC that includeschild mental health services would provide teach-ers with access to infomiation about mental healthdisorders and treatments and train them to managemental health problems in the classroom. The pro-grams should aim to provide role models andresources to increase mental health resilience tocombat the deleterious effects of low SES (Chen &Miller, 2012). One pilot study of the implementa-tion of comprehensive mental health services attwo inner-city elementary schools demonstratedimpressive program effects and satisfaction after thefirst year (Walter et al., 2011). Another pilot studyfound school-based mental health programs tohave greater retention than neighborhood healthcenters and positive effects on behavior and aca-demic performance (Atkins et al, 2006).

Adolescence is a time when youths in low-income households are particularly vulnerable tomental health challenges, but it also provides inter-vention opportunities (Dashiff, DiMicco, Myers, &Sheppard, 2009). Before the dramatic increasefrom two SBHCs in 1970 to 1,200 in 2000, manystudents across the United States did not use tradi-tional sources of health care, such as annual doctorvisits. Instead, they relied on sporadic emergencyroom visits for medical care (Rappaport, 2001).On average, 60 percent of students in schools withan SBHC enroll for services, and 70 percent ofenrolled students use them (Rappaport, 2001).Trained counselors and psychiatrists should be pre-sent at SBHCs, because this would expand the ser-vice offerings to include mental health careservices; psychiatrists would be able to cany outtherapy, assessment, and psychopharmacology(Rappaport, 2001),

The establishment of comprehensive mentalhealth services in schools could be very effective inreaching disadvantaged children who would other-wise not have access to these services, A compre-hensive mental health pilot program was recentlycarried out in two inner-city public schools in amajor midwestem city (Walter et al,, 2011), Afterone year, students covered by the program hadsignificantly fewer mental health difficulties, lessfunctional impairment, and improved behavior.They reported improved mental health knowledge,


attitudes, beliefs, and behavioral intentions. Teach-ers were also more proficient in managing mentalhealth problems in their classrooms (Walter et al.,2011).

Armbruster and Lichtman (1999) reported simi-lar findings when they evaluated mental health ser-vices in 36 schools established by a university-affdiated children's mental health outpatient chnic.The results indicated that school-based mentalhealth services show improvement comparable tothe clinic-based services and have the potential tominimize the gap hetween service need and utih-zation by engaging low-income children whowould otherwise be unable to access mental healthservices. Teachers attested that students engaged inthe services had improved overall functioning, andschool personnel reported that acadeinic perfor-mance, behavior, and attendance had improved.Such school-based interventions would be anappropriate response to studies that have identifiedurban, disadvantaged, minority children fromsingle-parent homes as the most at risk for prema-turely cutting off clinic contact (Armbruster &Lichtman, 1999). Social workers should advocatefor the expansion of SBHCs and other school-based services, especially counsehng and mentalhealth services.

Urban Churches and Pastoral CarePastoral care can also be an important feature of acomprehensive mental health service plan. Socialworkers and other practitioners should engage andtrain urban clergy and lay ministers to provideshort-term counseling and referrals for longer termmental health care. Clergy represent a significantmental health resource for people who otherwiselack sufficient access to care. This approach alsobuilds on the central role of the church in manyHispanic and African American families and com-munities (Young, Griffith, & Williams, 2003). Asimilar model could also be extended to Jewishand IslaiTUc religious leaders.

Addressing the Needs of the HomelessA number of effective policy-level interventionscan be used in cities to address the high levels ofmental illness within the homeless population.Chief among these is the "housing first" approach,which includes the placement of homeless individ-uals with severe mental disabilities in supportivehousing as the first step in treatment. An evaluation

of the work of one such program in New YorkCity between 1989 and 1997 revealed that peopleplaced in such housing experienced marked reduc-tions in shelter use, time incarcerated, hospitaliza-tions, and length of stay per hospitahzation.Placement in safe and secure housing was accom-panied by improvements in mental health and a$16,281 reduction in public funds spent per personper year (Culhane, Metreaux, & Hadley, 2002).Social workers should advocate at all levels of gov-ernment for housing-first policies.

Reevaluating Urban Mental Health ServicesGiven the urgent need for more accessible mentalhealth services, health care delivery systems in citiesneed to be reevaluated. Using mental health careto improve mental well-being, while at the sametime rebuilding a sense of community efficacy inareas of urban poverty, requires deeper changesthan just mental health intervention. Mobilizationto advocate for social policies including employ-ment, housing, and social services is also needed(Latkin & Curry 2003). Social workers shouldmobilize coalitions across sectors involving agen-cies, organizations, and individuals to address con-textual barriers to effective mental health care forlow-income urban communities. Such a compre-hensive intervention could put an end to the con-tinual inner-city cycle in which mental disorderand social disorder fuel each other.

CONCLUSIONAs a result of Stressors present in the urban environ-ment, those living in cities are at greater risk ofdeveloping mental disorders than those living insuburban and rural areas. Those who experiencethe highest risk of mental disorders are disadvan-taged populations within these urban communi-ties. As a result of the complex forces that cometogether amid concentrated urban poverty, thereexists a bidirectional, cyclic, and reinforcing rela-tionship between poverty and mental illness in theinner city. Social disorder and violence, by under-mining efficacy and promoting feelings of power-lessness, are key agents in perpetuating thisrelationship. In order to interrupt the cycle andachieve progress, social workers need to workwith community stakeholders to implement acomprehensive mental health care system thatcrosses traditional health care provision boundariesby mobilizing a variety of community institutions


(including schools, churches, and law enforce-ment) and professionals (including social workers,teachen, pastors, and police) to overcome bardento accessing mental health care services. In light ofthe relationship between SES and mental illness,the development of effective interventions thataddress urban mental health could also help reduceurban poverty and social problems. Advocacy bysocial workers to mobilize cross-sectoral coalitionsand the political will to create policies and pro-grams to address barriers to mental health care ser-vice provision in inner cities are crucial forimproving mental health and reducing urban pov-erty and dislocation.

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Ujunwa Anakwenze, BA, is a student, Department of Soci-ology, Harvard University, Cambridge, MA. DaniyalZuberi, PhD, is associate professor of social policy. Universityof Toronto. Address correspondence to Daniyal Zuberi, Univer-sity of Toronto, 246 Bloor Street W, Toronto, ON MSS 1V4Canada; e-mail: [email protected].

Original manuscript received January 9, 2012Final revision received July 16, 2012Accepted September 4, 2013Advance Access Publication August 13, 2013

EconocideElimination of die Urban PoorAlice Skirtz

Econocide: Elimination of the Urban Poor tells the storyof how an overweening focus on economicdevelopment, in concert with biased housing poh-cy practices, and a virtual abandonment of civic re-sponsibility, has forsaken tlie tirban poor m Cincin-nati, Ohio. Alice Skirtz shows how the city has usedlegislation and the administration of public policyto serve the ends of privatizing pubhc assets anddisplacing people who are perceived as undesirablebecause they lack economic power and privilege.

Skirtz argues that enactment and implementa-tion of legislation grounded in contempt for tlieeconomically disadvantaged and schemes contrivedto keep affordable housing off the market and toreduce or devolve essential social services have re-sulted in gross economic inequities, manifest In acollectivity she identifies as "economic otliers."

ISBN: 978-0-87101-424-5 2012 Item #4245182 pages $24.99

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Mental Health and Poverty in the Inner City