On depression and resilience in Trujillo
“What did you eat today?” Claudia asks.
“Some rice and a salad,” answers Paola, sitting on a gray, threadbare couch in Claudia’s office. “But I don’t have money for water.”
It’s Thursday afternoon, during Paola’s regular appointment for mental health counseling with Claudia at the SKIP (Supporting Kids in Peru) office in El Porvenir, an impoverished area on the outskirts of Trujillo on the coast of northern Peru.
Today, Paola’s hair is parted in the middle and tied in a neat bun at the back of her head. She wears a black skirt and a light blue T-shirt. A touch of mascara outlines her eyes. She faces Claudia, who sits at a wooden table across from the couch.
In American-accented Spanish, Claudia asks, “And how are you doing today?”
“More or less, always with problems.” Paola’s eyes fill with tears.
“We talk about what it’s like to be a single mom with no money and no support,” Claudia told me during our first interview. “When I first met Paola, she seemed so hopeless. She had this out-of-control teenage son, three other children to look after, and no money.”
Claudia is a volunteer therapist at SKIP, the NGO where Paola’s younger sons spend their afternoons in supplemental lessons. Run by foreign and local volunteers, the programs include educational opportunities for children, social work and economic development programs for their parents, and mental health services.
SKIP’s office, a compound of classrooms, sports areas, and meeting rooms, is on the same block as Paola’s house in El Porvenir, on the outskirts of Trujillo. Situated on the arid coast of northern Peru, Trujillo is far away from the well-marked trail between Cusco and Machu Picchu. When I flipped through my Lonely Planet, I found nothing about El Porvenir and only a few notes about Trujillo’s colonial churches, ceviche, Moche ruins, and the famous couple’s dance, the Marinera.
El Porvenir is a short taxi ride away from the churches and butter-yellow colonial buildings in Trujillo’s main square. The sign at the entrance to the neighborhood advertises a hand-painted shoe, a primary product of the area, usually hand stitched and sold for 2 soles (about $0.75). The area is also known for violent crime. The dusty, potholed streets are lined with concrete houses with unfinished roofs, covered by orange tarps and sheet metal, with support beams sticking up into the sky against a horizon marked by grey mountain peaks.
SKIP has been operational since 2003, when a group of British and Peruvian volunteers bought a concrete building on the corner of Maytna Capac Street, where it would be easily accessible to the families most in need. They also sent volunteer teachers into local public schools in El Porvenir to assist with tutoring and classroom management.
In time, SKIP saw the need for other programs to support the children’s parents, and so the organization grew to encompass a holistic approach. While it’s possible to send a child to free tutoring and then assign some homework at the end of the day, there might not be a table at home on which to do the homework. SKIP added an economic development component, where they made low-interest loans available for furniture and home construction, or for families to put towards starting a business or for medical emergencies. They also started offering training programs for the mothers to learn how to make jewelry or handicrafts, which they can sell to supplement their families’ income.
When volunteers saw that many of the community members seemed to struggle with mental illness, they added counseling and psychotherapy services, or psychologia, as it’s known among the SKIP families.
It is in this branch where Claudia serves as the Coordinatora de Psychologia and as SKIP’s only therapist. Because it’s a volunteer position, it’s difficult to find people, foreign or Peruvian, willing to take the job. With her all-pink outfits, Callista Gingrich hair, and California accent, Claudia wouldn’t look out of place in a Beverly Hills psychotherapy office. Instead, she works out of a blue room upstairs in the SKIP compound, with a rickety table, an overflowing box of client folders, and a window that shoots a beam of light directly into her eyes every afternoon.
Here, she meets with Paola on Thursday afternoons while Paola’s two youngest boys attend SKIP classes. Claudia also provides individual therapy to Paola’s oldest son, Arturo, as well as to the six to eight other clients she sees regularly. Additionally, she runs two separate group therapy sessions for boys aged five to seven and teaches parenting workshops, all free of charge.
Before moving to Peru, Claudia spent most of her life in California, where she worked as a bilingual educator and psychologist, while also managing her family’s ranch.
“I was living in a community with the rich and famous, and playing a lot of tennis, but I wanted something more,” she told me. She’d separated from her husband, and her two daughters had left home and successfully launched their careers elsewhere. “So I asked my good friend Google about volunteer opportunities in South America.” When she learned that SKIP was looking for a psychologist, she made plans to volunteer for a few weeks.
That was a year ago. Since then, she has accepted a paid position for the next year, and doesn’t see herself leaving anytime soon. She feels she has a good rapport with her clients — the mothers who attend her classes — and with the children in her groups.
Despite the fact that seeking mental health treatment carries a stigma in Peru, she says people keep asking for sessions. A preteen girl who wants help dealing with a bully at school. A heartbroken teenage boy whose first girlfriend cheated on him. A father who wants help with his son who ran away to find work to buy food for the family. A young boy who has behavioral problems at school because at home his parents beat him with a belt.
Some questions can be addressed in a few sessions. Others take time.
Claudia feels like nobody else at SKIP is qualified to handle her caseload. She is the only SKIP volunteer with a master’s degree in clinical psychology and fluency in Spanish. But even she recognizes she’s still an outsider. How can someone from the United States — with different cultural expectations, standards, and structures — provide meaningful help?
Paola lives just down the street from SKIP, in the white house with the red stripe. When SKIP first opened, she could see the volunteers coming and going; later she saw kids and volunteers playing together outside the SKIP building, and she asked if maybe her kids could join.
To join SKIP takes nearly a year of home visits, poverty assessments, and training workshops for parents to help them prove that there is need at home and that they are committed to allowing their kids attend the programs. All four of Paola’s children were able to enroll, which meant they could have after-school tutoring and recreation, as well as help with behavior problems.
Paola started her own therapy because of problems with her teenaged son Arturo, who had become angry and distant, staying in bed all the time, skipping school, and becoming violent with his little brothers. When Arturo stopped showing up for school, the volunteer teacher provided by SKIP referred him to Claudia, who took him on as one of her individual clients. Around the same time, Paola contacted Claudia and asked for an appointment to discuss what was happening in the family.
For Paola’s first session, Claudia did what she calls a “joining session,” in which she builds her client’s trust. She starts by talking about little things. Light conversation. Who is in the family? How is your day going? What is daily life like? Once a level of trust is established, she can ask more personal questions, such as, What brought you here today? After every session, she makes sure to ask, How can I help? “Help” could mean something concrete from another branch of SKIP, or another session to talk more.
For Paola, “help” meant a lot of different things.
Like many SKIP participants, Paola had lived a hard life marked by resilience. She was born on a farm in the village of Huamachuco, in the nearby mountains of La Libertad. She spent her childhood working with her nine siblings on their family’s farm, growing yucca, potatoes, and corn. They worked whether or not there was food to eat. She left school when she was seven. When she was a teenager, her older sister helped her get a job working as a domestic helper in Trujillo.
Then she met her husband, and they had a daughter and three sons. They moved into the white and red house. Her husband worked, and she was able to stay home to raise the children. There was never quite enough money, but the kids were able to go to school and everybody had enough to eat.
Arturo idolized his father. Because he was the oldest son, Paola thought that Arturo had a special place in his father’s heart. But when the two little brothers arrived, within two years of each other, the father stopped doting on Arturo, favoring the younger children instead. He said that it was because the little ones were blancos, like their father, while Arturo was moreno, dark like his mother. Arturo, who was treated like a prince before, was now the family outcast.
Then the youngest son, Roberto, got sick. Nothing seemed to help, even though the family made trip after trip to the hospital and the pharmacy while the bills piled up. They even took him to Lima for two weeks to see a specialist. Though Roberto eventually recovered, the financial and emotional costs were high.
Just as Arturo was entering his teenage years, his father walked out, right after boasting to his eldest son that he had a new family: a girlfriend and a baby on the way. He had met her while he was working as a cobrador, an attendant on the vans (called combis) that zip around Peruvian cities and serve as low-cost, somewhat unsafe public transport. The woman who became his girlfriend had been one of his regular passengers. Soon she was pregnant, and Arturo’s father disappeared, leaving Paola with four children and no child support.
A year later, they hadn’t heard anything from Paola’s husband. While Arturo nearly fell apart, his mother just went through the motions. She’d go to Trujillo and clean an apartment, then come home and maybe fix a meal. Many times, her oldest child, Maria, would cook dinner, see that the little ones ate, break up any spats, and put them to bed.
“I’ve had to learn to be both a mother and a father,” said Paola when we talked in the blue room one day. Once, when Arturo refused to leave his bed, she marched over with a pitcher of water and tossed it on him. He spluttered and yelled, but he left the house and went to school. After a few sessions talking to Claudia, he now goes to school every day. He doesn’t do any homework, but it’s still progress.
Then Paola talked about her daughter, Maria. Maria had gotten a scholarship to study in a pre-university program, one of the first SKIP students to receive such an award. As Paola described how proud she was, her face crumbled, and she choked out a few words I couldn’t understand. I looked to Claudia, who translated:
“She left school when she was seven and she can only read a little bit. She feels sad about the missed opportunity but so proud of her daughter.”
I stopped scribbling notes. My chest felt tight. I looked down at the pen and paper in my hands, but could not look Paola in the eye. I put the pen down and pushed the paper away. Claudia reached out and took Paola’s hand, and I awkwardly laid mine on top of theirs.
A few months later, Paola was again on the couch, trying not to look at the window with the sunbeam. She explained that Maria had to leave school because there was no money to take the bus each day to the classes that were free through her scholarship. Instead, she spent her days babysitting for her younger cousins, making jewelry to sell in SKIP’s artisan collective, and visiting the library as much as she could so she didn’t fall behind in her studies.
Arturo had also left school to work, but only because of the teacher’s strike that left his school closed for two months. He spent his days pasting together shoes, making three soles for every 12 pairs. At first, he tried to keep the money for himself while his mother had none to feed the family, but after they fought about it, Paola managed to convince him to give some of his money to her.
Paola had received a loan from SKIP to start a small menu-style restaurant in her house, but she couldn’t pay for the gas to cook the food, so she closed the business. She also couldn’t make the payments on her loan to SKIP, so the interest continued to compound.
Because her two youngest boys are at home now, she can’t go to Trujillo every day to clean apartments. She has a job cleaning the SKIP office twice a week, where she can bring her boys with her and have them play while she works, but that job doesn’t pay enough for food. She also makes jewelry in SKIP’s artisan collective, which she sells for 10 soles (about four dollars) apiece. She used to wash clothes for other families on her block, but since her water got cut off she hasn’t been able to do that either.
To eat, she borrows from her sister, who owns a corner bodega. There, Paola can get basic foods like rice and cooking oil, but she’s now over 900 soles in debt, on top of the money she owes SKIP.
Not long ago, her husband returned. It was a brief, unannounced visit, the first since he left two years ago. He stopped by the house to leave 300 soles for Arturo’s school supplies, without which Arturo would fail his classes. And to tell them that the new baby had been born.
“The children didn’t know him. He was like a stranger,” said Paola. Her voice cracked and she wiped at her eyes. “The children said to me, ‘Ask him for money for my shoes.’ And I said, ‘Ask him yourself, he’s your father.’ But they wouldn’t even hug him.”
He stayed for just an hour and then disappeared again. Since then, Paola has worked on getting a denuncia, a legal procedure that will officially end their marriage and force him to pay a percentage of his salary toward child support. It took her several months to get the paperwork together, even with the help of a pro bono lawyer. But they don’t know how to track her husband down, and if he does get served, payments only begin on that date, with nothing for the time preceding.
Even if they do find him, I wonder, will it take away the hurt he left behind?
Paola didn’t want to get the denuncia. It was a lot of work, and there were no guarantees that she would get anything from it. But Arturo and Maria insisted. They were angry and they wanted something from him, anything, even just money for a meal each day.
“And do you feel that SKIP has helped you?” I asked Paola after she’d finished her story.
Here in Peru, she explained, there is very little help available. If a child needs help with schoolwork, the parents have to hire a tutor. If you cannot buy school books, supplies, or uniforms for gym class, you automatically fail, and there is no way to get financial assistance for these things, even in the public school that Paola’s sons attend.
But because SKIP provides these things to her family — extra classes, tutoring, shoes and uniforms for the kids — she said she’s incredibly grateful. Of course, she wishes they could do more. Help her with her debt, maybe help her with childcare so she can look for a job. Maybe they could look at each family’s individual needs instead of deciding beforehand what they do and do not cover. But she wanted me to know that was her only critique.
For the future, Paola mentioned her children first. She wanted them to study, to get good jobs and to be happy. Maybe someday she’d be able to start her own business, open one of those little bodegas like her sister. She doesn’t see herself getting remarried or even having another romantic relationship. She just wants to work for her children’s future.
At the beginning of her work with Paola, Claudia diagnosed her with major depressive disorder, colloquially known as depression. But depression is a Western label, one that means different things in different places. In some countries, it may mean antidepressants, appointments with a therapist, or even compensation from work. Paola can’t take antidepressants; there’s no money for them. And since she doesn’t have a formal job, she can’t get health insurance to cover paid therapy sessions or days off to recover.
And what is the help that Claudia offers at the end of each session? A little less worry because Paola’s sons can get free tutoring from SKIP volunteers, instead of failing classes because they cannot pay? A few suggestions on how to get a loan and start a business? Ideas on how to manage children as a single mother, who never had a childhood herself?
What does a psychological diagnosis matter for a person living with extreme poverty, abuse, and abandonment? Even the terms “poverty” and “abuse” are perhaps relative. While it’s possible to put a dollar amount on poverty, what Claudia views as “abuse” might be, to Paola, ordinary. If Paola believes that her husband is entitled to leave without a trace and never answer for the hurt he left behind, Western therapy approaches and antidepressants are unlikely to help. Will an unjust social situation created by outside forces — extreme poverty, children going hungry and having to leave school, a father who can abandon his children — really be changed by a little white pill?
Is Paola sick, or is the situation sick?
Many people in Peru feel mistrustful of seeking help for mental illness because, as Paola explained, there is a huge connotation of shame. But it’s questionable whether the framework of mental health diagnosis and treatment — the medicalization of misery — is appropriate to this situation.
In El Porvenir, where there are people from villages all over Peru — the desert, the mountains, the jungle — people confront the challenges of life in urban poverty. There is violence, crime, deception, and corruption, but also the loss of a sense of community that many people once enjoyed in their small villages. In some cases, people living on the same block might not speak the same language because they come from different regions and different ethnic groups. Perhaps, because people feel isolated and uprooted, this is why an organization like SKIP, which provides a sense of communal support, through classes, workshops, and therapy, has been welcomed and allowed to grow.
But does SKIP’s therapy component, from a different cultural context, overstep the community that the people had before?
Claudia believes it does not have to. For her, a Western diagnosis is a way to make a plan for treatment; it shouldn’t be a label for the client. Hopefully the diagnosis changes in a few months.
Of course, nobody has to come back if they choose not to. Claudia states, “It is the height of arrogance for a therapist to think they have the answer to someone else’s life.”
Back in Claudia’s office, the sunbeam is getting lower. Paola shifts a little on the couch to avoid the desert light, still sharp even in the late afternoon.
Paola says, “This week, Ernesto, my second son, said, ‘That’s three Christmases without my dad. I miss him so much. Why can’t you contact him for me?’”
When the father still lived with them, there were always presents on Christmas. This year, since the children did well on their exams, they were asking for their prizes: toys for Christmas that they saw on television. “But I always have to say, vamos a ver, we shall see if there is enough money.” She doesn’t want to tell them that the money is never enough.
“And how are the boys? Are they fighting?” asks Claudia.
“Well, yesterday Arturo and Roberto were fighting because Arturo had a flier from the SKIP Father’s Day party, and Roberto wanted to cut it up and use it in his art project. Roberto said to Arturo, ‘You don’t have a father. He left us and he’s not coming back.’”
“And what do you say to Arturo when his brothers say these things?”
“I tell him to ignore them, or I take him somewhere else.”
Claudia considers this for a second. “I think Roberto has accepted that the father is not coming back.”
“Yes, he is more realistic,” says Paola, her eyes misting. She looks down at her clasped hands.
“Are they excited for the SKIP Christmas party?” Claudia asks.
“Yes, they are counting down the days.” When Paola was a child, there was never any money for gifts, or even for hot chocolate and paneton, traditional Christmas treats. Now, at least, her children can have these things.
I realize suddenly that Paola has spoken about herself only a few times today, and only to say, “I feel a bit bad,” when she was describing the situation at home, where her children were asking about Christmas presents. Instead, her focus has been on the children and how they behaved, and also on the family’s other problems, such as their lack of funds. Even in her therapy session, she’s putting her children’s needs first.
After the session, Claudia and I take a walk around the neighborhood to get some air. We wander along the unfinished sidewalk, past an elderly woman sitting in front of her house, stitching a shoe and chatting to a young girl who sat next to her. A stray dog pads by, nose to the ground.
“I just wish there was a way for Paola to get out of debt. It would make such a difference,” Claudia remarks as we round the corner and head back to the blue SKIP office. “But at this point, it’s not psychotherapy. It’s crisis counseling.”
While it may take years for Paola to get out of debt, little things do seem to make a difference. Paola no longer has the diagnosis of “major depression.” There are fewer fights at home. All of the family members are active participants in the SKIP community. They are surviving, if barely.
I think back to the end of the session, when Claudia had asked, as she always does: “Is there something I can help you with today, with the children?”
Paola blinked a few times. “No senora, thank you,” she said. Then she got to her feet, said goodbye, and left to meet her sons and walk them home.