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BY: ARTURO CARRILLO, PhD, LCSW, and CAITLIN L. O’GRADY, PhD, LCSW

Responding to Chicago Communities

Illustration by: Roy Scott

In 2015, Saint Anthony Hospital's community health needs assessment ranked mental health as the highest perceived problem in the community, with 82 percent of respondents rating it a major problem. Concerns for mental health far outnumbered diabetes (69 percent), community violence (64 percent), nutrition, physical activity and weight (64 percent), substance abuse (63 percent), family violence (50 percent), and tobacco use (50 percent). The findings also highlighted that self-reported chronic depression, along with fair/poor mental health, was notably higher among adults under 60, Latinos and low-income residents.¹

For leadership within Saint Anthony Hospital, the findings confirmed the importance of the hospital's investment in the Community Wellness Program, a model for community-based social service delivery that has been in operation for more than 20 years. A fully funded department of Saint Anthony Hospital, the Community Wellness Program started as a small community resource center in the late 1990s. It has grown to be two fully staffed community centers in the Little Village and North Lawndale neighborhoods and two satellite locations in Brighton Park and Gage Park, offering free social services that have evolved throughout the years in response to the various socio-emotional needs of community residents. The program has focused primarily on four areas: health care access and navigation, parenting supports with an emphasis on childhood development, health education and mental health services.

CULTURALLY ATTUNED SERVICES
The Community Wellness Program's mental health services are grounded in an understanding of community members' cultural values and beliefs and their experiences as defined by their environments. The Little Village community center, for example, is located in a neighborhood with a predominantly Mexican immigrant population, and the center provides mental health services to uninsured Latino immigrant adults. The mental health services are culturally attuned, trauma-focused and long term. Providers recognize the importance of offering bilingual and culturally affirming services, a fact that is clear from the moment that community residents enter the center's waiting area, where they are greeted with a vibrant mural of Our Lady of Guadalupe.

Saint Anthony Hospital also recognizes that to provide culturally affirming services, the programming must be responsive to community residents' lived experiences. Little Village residents accessing mental health services through the Community Wellness Program often have experienced trauma in their country of origin, during their migration journey and after their arrival in the United States as they encounter discrimination, exploitation and limited access to resources.

Mental health services at the Community Wellness Program are intended to promote individual, family and community healing from trauma through counseling services for individuals, couples and groups. Central to the model is its free service provision. Considering that mental health program participants commonly have identified cost as a barrier to accessing mental health services through other local providers,² the Community Wellness Program promotes health equity by ensuring that all community residents, regardless of income and insurance status, have access to long-term, health-promoting services.

As the Community Wellness Program has expanded, it has demonstrated the same commitment to delivering services that are aligned with the experiences of community residents. An evolving understanding of the lived realities of the predominantly African-American population in Chicago's West Side neighborhoods continues to inform mental health service delivery at the community center in the North Lawndale neighborhood. Upon establishing mental health services there in 2014, a community needs assessment was conducted to shape the mental health services provided.³

The CHNA explored residents' experiences with mental health service providers, as well as community mental health overall. As we talked with residents and providers, one of the primary concerns that emerged was the importance of family members' emotional wellness and of intergenerational health needs. However, more importantly, residents identified a long-standing, complex mistrust of the mental health industry as a response to the history of harm by intrusive, pathologizing services.

One example came up in a focus group held at a local elementary school, where a mother shared her story of pain and frustration when she sought out mental health support. She had recently moved from out of state, escaping a violent relationship with the father of her child. She was living in a shelter right before her move and seeking counseling. At the same time, she was trying to gain legal custody of her child. She said her mental health records were used in family court as evidence of instability and inability to care for her child. It is difficult to convey the mix of anger and betrayal that she expressed.

Another parent, a father, shared his own story of frustration. He spoke about struggles in his life that reflected being moved in and out of foster care placements and group homes and experiences of repeated physical abuse. Yet, he said, doctors or the professionals he spoke to not only often were unhelpful, but they also left him with the perspective that such professionals could neither help him nor be trusted.

In response to these kinds of stories from community residents, the North Lawndale community center makes developing trusting relationships central to its model of service delivery.

MENTAL HEALTH WITHIN THE CHICAGO CONTEXT
Chicago serves as a case study of mental health access within an urban setting that has severe and persistent economic inequality. Chicago's high economic hardship communities comprise 26 predominantly Latino and African-American communities that rated highest on six indicators comparing social and economic conditions throughout the city.⁴ Saint Anthony Hospital's service area encompasses 15 of these communities on Chicago's West and Southwest sides. Saint Anthony staff can attest that residents in these areas are living with unmet mental health needs resulting from the impact of structural violence. Structural violence captures the understanding that systems create conditions of inequality, and these conditions of inequality cause harm in people's lives. Structural violence also perpetuates inequality by limiting people's access to the resources needed to improve their lived reality.

Experiences of poverty, unemployment/underemployment, challenges with housing, attending under-resourced schools, limited social service infrastructure and ease of access to firearms, among other factors, have a combined effect on the mental health of individuals and the well-being of families living in these marginalized communities. Not only do their experiences of structural violence impact personal mental health, but within Chicago's current mental health service landscape, opportunities to access trauma-focused counseling services are scarce. Between fiscal years 2009 and 2012, Illinois cut $113.7 million in general revenue funding for mental health services, making it the state with the third-highest amount of mental health funding cuts.⁵ In 2012, the city of Chicago closed half of its public mental health clinics.⁶ The shortage of public mental health access has resulted in the Cook County Jail becoming the biggest mental health hospital in the nation.⁷

COMMUNITY RESEARCH INITIATIVES
Informed by a growing recognition of how economic inequality impacts the communities the hospital serves, Saint Anthony Hospital has built on community partnerships to address the crisis of unmet mental health needs. As community-based organizations witness firsthand the need for mental health services and the lack of access for adults, we have collaboratively sought solutions and invested in filling the service delivery gap in a context where philanthropy funding is sorely lacking and state and municipal funding has been reduced.

In 2014, it was clear that the Community Wellness Program in Little Village needed more capacity to cut down waiting times and to serve more residents. In addition, many of the mental health program participants came from the neighboring community of Brighton Park, indicating the importance of documenting and addressing mental health needs in that neighborhood.

Saint Anthony Hospital helped the Brighton Park Neighborhood Council develop a survey to gain a thorough understanding of the mental health needs of Brighton Park residents. The questions were integrated into the neighborhood council's annual community health survey for which health promoters surveyed parents at all the public schools within Brighton Park, and they collected 578 surveys. The questions were designed to reveal not only mental health needs, but also the barriers to accessing services.

Findings were presented to hospital leadership, and the data showed that, by far, cost was the biggest access barrier out of a list of 10 (55 percent), followed by lack of health insurance (39 percent). Stigma was in last place (6.6 percent). Based on that data, Saint Anthony Hospital added two full-time bilingual therapists to increase the Community Wellness Program's capacity and begin to meet the mental health needs in Brighton Park. At the same time, the hospital added a mental health therapist to the budding community center in North Lawndale. The survey has been repeated in the subsequent two years, and the findings were identical. The continued demand for free, trauma-focused mental health services for adults has outpaced the increased capacity, and there is a perpetual waiting list in Brighton Park for services.

Given the high demand for counseling services in Little Village and Brighton Park, Saint Anthony Hospital expanded its investigation of mental health needs throughout Chicago's Southwest Side. The hospital spearheaded efforts to conduct a mental health needs assessment across a 10-community area in partnership with community-based organizations including Universidad Popular, Union Impact Center, Enlace Chicago, BPNC, Southwest Organizing Project and Pilsen Alliance. In all, 2,859 adults were surveyed, and the partners conducted nine community focus groups in order to share findings with residents. Survey data identified that nearly half of respondents (49 percent) reported depression. More than one-third of respondents reported anxiety (36 percent) or acculturative stress (34 percent). The overwhelming majority reported interest in seeking counseling (80 percent).

The biggest reported barriers to access, out of 11 options listed, were cost (57 percent), not knowing where to go (38 percent), lack of health insurance (38 percent) and services not being available in their area (34 percent). In last place were social and individual barriers, including stigma (11 percent), belief that counseling will not work (10 percent), and disapproval by family or partner (9 percent).⁸

The findings indicate that the primary barriers to mental health equity among Latino immigrant adults are structural, not social. This survey led to Saint Anthony Hospital convening the Collaborative for Community Wellness, a coalition of local organizations, community residents and mental health providers who are committed to leveraging and building up local resources to increase socio-emotional wellness for community residents in marginalized communities.

IMPLICATIONS FOR CHARITABLE HOSPITALS
The story of Saint Anthony Hospital's Community Wellness Program reflects the hospital's commitment to promoting holistic well-being among underserved individuals, families and communities. The program can serve as a model for charitable hospitals across the nation.

Charitable hospitals receive tax-exempt status for carrying out activities that benefit the communities they serve,⁹ which means there are opportunities for charitable hospitals to maintain their tax-exempt status by implementing innovative health promotion programs that target identified priority community health needs. Although charitable hospitals often prioritize charity care to individual patients rather than investing in broader community health promotion activities,¹⁰ Saint Anthony Hospital demonstrates that investment in broad-based community health initiatives is possible. Informed by their ongoing engagement with the communities they serve and their understanding of community members' most pressing health needs, Saint Anthony Hospital has developed and implemented accessible, community-centered programs.

A national study of 300 charitable hospitals¹¹ reported mental health as a community concern for 68 percent of the hospitals that were surveyed. Saint Anthony Hospital's Community Wellness Program is a good example of how charitable hospitals can respond to the challenge of addressing unmet mental health needs. By providing free, trauma-focused, long-term mental health services for uninsured and underinsured adults, Saint Anthony Hospital gives marginalized residents in our community access to services that otherwise would be inaccessible and unaffordable.

In addition, through participation in community-engaged research initiatives focused on developing a more comprehensive understanding of the service needs and access barriers of community residents, Saint Anthony Hospital demonstrates its ongoing commitment to facilitating access to services aligned with community residents' needs. By engaging in ongoing assessment and investing in free, community-centered supportive services, charitable hospitals can promote holistic well-being and health equity within marginalized and underserved communities. In so doing, charitable hospitals can play a vital role in ensuring that regardless of income and insurance status, community residents may pursue their fundamental right to access health-promoting services.

ARTURO CARRILLO currently serves as program manager of the Saint Anthony Hospital Community Wellness Program's mental health and family support services and has been a part of its development since 2005.

CAITLIN L. O'GRADY is a recent PhD graduate who conducted her dissertation research on the mental health services at Saint Anthony Hospital's Community Wellness Program.

NOTES

1. Professional Research Consultants, "2015 PRC-MCHC Community Health Needs Assessment" (unpublished manuscript).
2. Caitlin O'Grady, "Culturally Competent Mental Health Practice: A Case Study of an Organization Serving Latino Immigrants" (doctoral dissertation, University of Illinois at Chicago, 2017).
3. Suzanne Zoheri Chopra, "Saint Anthony Hospital: Community Wellness Program Needs Assessment for Mental Health Program in North Lawndale" (unpublished manuscript, 2015).
4. Jaime Dircksen, Nikhil Prachand et al., Healthy Chicago 2.0: Partnering to Improve Health Equity 2016-2020 (Chicago: City of Chicago, March 2016).
5. Ron Honberg et al., State Mental Health Cuts: A National Crisis (report by the National Alliance on Mental Illness, March 2011). www.nami.org/getattachment/About-NAMI/Publications/Reports/NAMIStateBudgetCrisis2011.pdf.
6. Frederick H. Lowe, "The Closing of the Woodlawn Mental Health Center Disrupted the Lives of the Black Men It Served," Social Justice News Nexus, March 30, 2015, http://sjnnchicago.medill.northwestern.edu/blog/2015/03/30/the-closing-of-the-woodlawn-mental-health-center-disrupted-the-lives-of-the-black-men-it-served/.
7. Matt Ford, "America's Largest Mental Health Hospital Is a Jail," The Atlantic, June 8, 2015, www.theatlantic.com/politics/archive/2015/06/americas-largest-mental-hospital-is-a-jail/395012/.
8. The Collaborative for Community Wellness, "Uplifting Voices To Create New Alternatives: Documenting the Mental Health Crisis for Adults on Chicago's Southwest Side," Saint Anthony Hospital Center for Community Wellness, 2017.
9. Sara Rosenbaum et al., Improving Community Health through Hospital Community Benefit Spending: Charting a Path to Reform (Washington, DC: The George Washington University Milken Institute School of Public Health, 2016).
10. Rosenbaum et al.
11. Rosenbaum et al.