Case Study of 1

A red ticket-dispenser in the psychiatric department instructs me to take a number and wait until it’s called. So, I do.

I am trying one last time to get mental health treatment. At least, that’s what I said two months ago to trick myself into following through on it. Suppressing doubts about whether this latest attempt would work, I looked up my health insurance’s list of local mental health care providers. The first few weren’t taking new patients. The next two said they didn’t take my insurance, even when I said I was sure they did. The next one was a hospital. The receptionist said there was no room for new patients. I told her that I could wait if needed and no, I am not suicidal, but I need help. She found me an appointment in two months’ time.

So two months later, I’m here. Another hour and I’m called to the registration desk. The receptionist says she isn’t sure if they take my insurance, and to go to the financial counseling department and then come back. Her coworker disagrees, so she just calls the counseling department instead, who confirm the hospital takes the insurance. The receptionist hands me a yellow paper square with my new number—“We call people by numbers here, not names,” she says—and instructs me to wait. The paper has a big “1” written on it. A good sign, I think, looking at the overflowing waiting room.

A nurse calls out “1” an hour later and I pee in a cup and return to waiting. Thirty minutes later, a therapist appears, asking for “1.” She seems nice, though she doesn’t look up from her computer when she asks if I’ve ever tried to kill myself. But when I tell her I how I’m doing, she tells me she is sorry and I decide that she sounds like she means it. We schedule a follow-up and she walks me to the psychiatrist’s office.

I enter and begin repeating the answers I’ve just given the therapist to the standard mental health questions. No, I am not suicidal. I live with roommates. I do not have children. If I’m out with friends, I can definitely down a few drinks, but that happens maybe once a week. I work full-time. I have tried Wellbutrin and Effexor, but they did not work. I am desperate for something to work and willing to do what is needed to get better. I am trying to be responsible.

***

I blame the medical bills.

They pile up in a corner of my room, collecting cobwebs under the bed. Every few months, I gather them up, opening a few. There are doubles, triples, of the same bill, differing only in their dates. Others are solo, lone socks in the pile. I consider using them all as wallpaper.

After I was hospitalized with a particularly nasty skull fracture a few years ago, something snapped; suddenly, I could barely call a doctor. It might have something to do with the way the hospital treated me—a nurse said that they had all believed I was uninsured and had given me “different” treatment because of it—but I think it’s the bills’ fault. They started showing up mere weeks after I was discharged. They never slowed down, no matter how often I wrangled with my insurance company on day-long phone calls. I was broke, and the bills broke me.

So after the first hospitalization, hospitalization became my health care strategy. If you have a severe injury, the hospital will find you a primary care physician and force you to book an appointment. For the skull fracture, they did likewise for a psychiatrist, among other specialists to deal with the aftereffects of the injury.

It seemed great, but my enthusiasm waned when I left the hospital. Each doctor is a co-pay, and that’s if you’re insured. Without insurance, my first hospitalization would’ve cost $39,000 (I made $10 an hour at the time). With it, I was still on the hook for a few thousand dollars. Dizzying diagrams of future appointments and work schedules began to dot my notebooks alongside unworkable budgets. But I was unwell, so I lost track. Within months, I was missing appointments. Soon enough, I couldn’t remember the doctors’ names.

Eventually, I was without care again until being hospitalized in a new city, New York, where I’d just moved. I had no doctors here, and my mental health was declining precipitously. I chose to interpret this turn of events as a gift.

After a false start—I went to a hospital in my neighborhood, Bushwick, only to be discharged because the doctors “couldn’t figure out what was wrong”—I found a hospital rich people go to that accepted my insurance. My wish had been granted: I’d lock down future doctors. Thank god for my prematurely decomposing body.

It didn’t work out. The doctors were understandably focused on my physical ailments. When I mentioned other health problems, they told me to wait until I recovered to worry about the rest of it.

The night I was discharged, I was groggy, floating on morphine. I had complications that required the procurement of an ambulance to drive me home. Follow-ups were scheduled hastily as I was rushed out the door. Someone from the hospital called with the PCP’s information while I was horizontal, strapped to a stretcher. I scribbled the information on the back of my discharge papers. When I got home, I realized the pen had been out of ink.

Despite this, I found the doctor. I couldn’t remember any details about the appointment, but I returned to the upper-east-side hospital and spent a day asking administrative employees for help. Finally, a saintly woman in a tucked-away office, packed with precarious piles of papers, the Office of Historical Memories or something, tracked down the information.

As it turned out, the PCP was actually a clinic; I was seen by different doctors-in-training every time. It was rushed, and no one seemed to have notes. I asked for a psychiatry referral. They told me they couldn’t do that, and to find a psychiatrist myself. After further prodding, they offered the numbers of two psychiatrists. I again scribbled this information on the back of medical forms and left.

They remain in my room, a monument to the vast reserves of the human spirit—I, of course, never got an appointment. The first time around, it took me a year, maybe two, to disappear from the health care system post-hospitalization. This time, it took weeks.

I spent a year like this. I’m fortunate to have never had the type of depression that brings suicidal thoughts and extreme highs and lows; mine is the flat-line variety. Someone who takes days to respond to a text message does not have the ambition required to die—no thanks, sounds like work. But the depression got worse than I’d believed it could. And the bills kept arriving! The calls from unknown numbers multiplied. Once a month or so I answered one. Every time, it was a debt collector.

***

So I am here, making a good-faith shot of it, answering the psychiatrist’s questions.

We get through all of them. After a brief silence, she says she cannot prescribe me medication. When I ask why, she informs me that I am an alcoholic, and antidepressants do not work with alcohol. I say I am aware of the “don’t drink on meds” rule, and if it’s really the case that the medication will not work if I drink, then so be it, I’ll drink lemonade at parties. “I am desperate, and willing to do what it takes to get better,” I restate.

“You could not quit drinking if you tried, and you will not try,” she says. She has known me for twenty minutes at most. “I will likely recommend you get addiction treatment, which entails three appointments a week, and then you can get on an antidepressant.”

Perplexed, I tell her I do not need addiction treatment, that I sometimes go weeks without a drink, and besides, I work full-time and what with my whole exhausted-depressive thing, there is no way I could follow through on three appointments a week. I think about a family member who was court-ordered to attend AA meetings three times a week after an arrest, and how little the judge cared that he might lose his job for taking that much time off. This is criminal, I think.

She says that she will add to her notes that I am in denial about addiction, and if I’d like to get my blood work done so she can see the results and formally decide what treatment to recommend, I can do so. In the meantime, can I quantify my drinking for her notes on my alcoholism, she asks.

“Would you say you take like, ten shots?” She actually says this. I can’t speak, so I laugh. She is withholding medication I need as a perverse moral means-testing, because I mentioned I get drinks with friends once a week. The only possible outcome, should I refuse to go along with it, is that I will go untreated, or will lie about my drinking habits to a future psychiatrist if I ever get to see one. She must know this.

“It took me so long to get this appointment,” I say.

She stands and gestures to the door.

I get the blood work done. As I leave, I stare at the room of waiting patients, some of whom were here when I arrived six hours ago. This is a hospital for poor people. I can’t stop wondering how many of them this psychiatrist will also withhold medications from unless they, too, agree to whatever preconditions she chooses. How many other doctors like her are there? The rich and the poor use drugs at the same rate, but there is no doubt in my mind this woman sees everyone here as an addict or a criminal and is determined to punish us for it. There are no consequences for her, but some of us will die.

I think about last year, at the Bushwick hospital. I doubt there were any millionaires in that packed emergency room. They’d discharged me late at night, on a cocktail of painkillers but still pulsing with pain, to walk home.

These hospitals are located in the heart of the city’s gentrification but apparently those who can, avoid them. I’d never step foot inside one of those places, friends say when I describe my day. Everyone knows not to go to those hospitals. But I didn’t, and neither did the hundreds of other people who were in the psychiatric department this morning. “Why are these places packed if everyone knows this?” I think, to distract from other thoughts, about how, exactly, I will wait out the months it will take to get a new appointment, with a new psychiatrist, in Manhattan.

Anyone reading this likely knows health care is a gruesome, deadly separate-but-equal system in the United States. Anyone who can avoid these hollowed-out institutions on which so many working-class people rely is acting quite reasonably in doing so. They are carceral and dangerous—sometimes filled with literal toxins, as if this country needed more symbolism. They kill us, even if we kill ourselves. They tell us we are criminals, and we agree—a plea deal is the best anyone can get. They say we are addicts, and we wonder whether we must be addicts if we are to survive. None of this is news, it’s just another data point. These are hospitals in the richest city in the country, but the funneling of resources away from them reproduces segregation—it’s how they got this way in the first place. And it is worse elsewhere.

I don’t have any proscriptions beyond what many people are already doing: pushing for universal health care so at least we can get rid of the damn financial counseling department and all the co-pays (today’s experiment left me $45 poorer), funding long-term mental health care, and otherwise creating a world with less alienation, less poverty, shorter workweeks.

I’m just mad, and the stakes are so high. US life expectancy has dropped for the third straight year, in part because more people are killing themselves. If I were the suicidal type, this might be the end of my rope. (I cannot insist enough that I am not, please do not worry.) I just wish all of it would be classified correctly, as murder: the mistreatment, the abuse, the insurance mix-ups, the lack of access in the first place, the disdain, the bills, what that psychiatrist did today. It’s homicide, on a mass scale: take a number, wait until it’s called.

20 thoughts on “Case Study of 1

  1. I’m sorry this happened to you. This is a horrible, barbaric system and it kills people every day. We will break it and build something better and more just, but until then I hope you find something that helps you get by.

    Liked by 1 person

  2. This is an extraordinary piece. Beautifully written. Incredibly insightful. And such an honest and so very sad commentary about our healthcare “system” in the USA.

    Liked by 1 person

  3. Something similar happened to me last time I tried to get treatment. I was told my high number of partners made me a sex addict, except we had not actually discussed any sexual history and I had not given any number

    Liked by 1 person

  4. Alex, you have made a deep and damning case against our broken system. Do not expect most of them to be competent, humane or rational. But you will eventually run into that one person or couple of people who are. You will wear down the system in the end if you don’t give up, and you will get your needs met. Don’t let them blow you off or defeat you. A way will open up to move forward, even amid infuriating frustration. Treat your right to finding proper medical care as an ongoing and sacred mission. You’re doing the kind and decent thing for yourself.

    Liked by 1 person

  5. I hope this article gets picked up by Huffington Post, The New Yorker, or similar.. Your writing needs a national audience. Thank you for expressing what thousands of us have dealt with.

    Liked by 1 person

  6. I wonder if it isn’t some kind of protocol, that if you drink or do other drugs they will not prescribe anything for you. I say this because the same thing happened to me several years ago. I went home, found I still had a refill on my old script, and I was set to go. But I was so angry at the system that refused to help me when I had totally surrendered myself to their mercy, when I had sought their help, and they humiliated me instead. I think I left all trust behind that day.

    Liked by 1 person

    1. If there’s a protocol, it’s only at hospitals for poor people. I also drink occasionally and I’ve never had trouble getting a prescription for anti-depressants. And I’ve certainly never had a therapist or doctor assume I’m an alcoholic after telling them I have drinks with friends sometimes.

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  7. You are a great writer. And I mean GREAT. This is probably little consolation to you at this moment, but remember so many are going through what you are going through but can’t capture an audience with their tale. You are giving your voice to thousands of people suffering.

    Liked by 1 person

  8. “We now live in a nation where doctors destroy health, lawyers destroy justice, universities destroy knowledge, governments destroy freedom, the press destroys information, religion destroys morals, and our banks destroy the economy.” – Chris Hedges

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  9. As citizen of a country with a universal health care system, with no co-payment at all, where 80 year old men with bladder cancer are given quadruple bypass surgery for them to enjoy a higher quality of life for as long as they live, I MEAN, WORDS FAIL ME. How can a developed country have such a primitive, barbaric health “system?” For shame.
    And I agree, you’re a solid writer. Take care.

    Liked by 1 person

  10. This is incredible. I’m almost crying.

    I’m declaring bankruptcy now, because my insurance simply will not pay for the critical mental health services I needed in March. I was told I needed to be hospitalized for 60 days. Insurance said they would pay for 5. I compromised on 35 days. My bill was $35,000. I’ve been reimbursed $1,000 so far.

    I was suicidal — I’m not now. I’m just broke.

    Liked by 1 person

  11. Alex, you are a fantastic writer. Thank you for illustrating your struggle (and the struggle of thousands and thousands of people) so eloquently.

    As someone who struggled with un- and under-treated depression from age 12 to age 26, who tried Wellbutrin, Paxil, Zoloft, and other drugs to little or no avail, I’ll share what worked for me. I will share it with the understanding that anybody in the throws of depression finds it difficult or impossible to undertake these things, but I will also share it in the hope that it may help you, or somebody else, when slowly implemented in a way that feels manageable.

    I went raw vegan for 6 months and found my mood greatly improved, and since then I eat plant-based (basically vegan with very little to no processed food). I also resistance train (with body weight, one doesn’t need a gym, there are lots of free YouTube videos if you have internet access) three times a week, and do low intensity cardio (walking) three to four times a week. This combination has kept me in a very functional mental health state for 12 years, when medication and counseling couldn’t. A combination of diet and exercise were necessary – one alone wasn’t enough to fully feel back to normal.

    I know everyone’s experience with depression is different, and we all have vastly different brain chemistry. I hope you receive the mental health treatment you deserve, and that these difficult times are one day a thing of the past. I admire your ability to advocate for people in similar circumstances while going through them yourself, and wish you all the best.

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  12. I am so sorry you’re going thru this. Sometimes I think it’s “their” way of saying “We have no idea how to help you”., which only leads to more anxiety and feelings of failure. Keep going and keep seeing other professionals until you find one that is willing to listen to you.

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  13. Brilliantly written. I hope people read this, especially people in the healthcare industry.

    So many people don’t understand how broken the healthcare system is. I have a congenital illness that went undiagnosed until I was 15. Doctors would refuse to listen to me and blame my symptoms on stress or hormones, or give me some diagnosis without really talking to/examining me. They invariably underestimated the severity of my symptoms. The more I talk to other women who have had experiences with the healthcare system, the more I realize that my experience is pretty average.

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  14. It’s possible to buy medications on the internet, or OTC in Mexico–why bother with these nasty therapists at all? All the doctors nowadays are obsessed with the idea that their patients are drug-seeking addicts. I went to a doc to have my blood pressure meds adjusted (I’m an old lady!) and the woman focused on a very minor migraine medication I used to take. It is not even a controlled substance, but she went on and on, even resorting to figuring out how many pills should be left from a year old script. I was so mad, I walked out. went to an urgent care joint, and got my new blood pressure meds.

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  15. Wow, what a horrible experience for someone who’s already having a bad time. Amerika really wants its people to FOAD if they’re not tickety-boo perfect. It’s SO wrong, and so unnecessary from a moral standpoint. Except in the United SStates, your life only as valuable as your bank account.

    I’m a registered nurse who’s worked in psychiatric settings in the U.S. (not much there, because there essentially is no psych care unless one is well-insured or old) Canada and now Australia. (I’m one of the few Americans who left the country after Bush II get re-elected; a decision that looks ever better in reTrumpspect) The big-city hospital system I worked for during three years in Vancouver was not perfect — overly medication-focussed the way American psychiatry is, IMHO — but people got cared for, even the down-and-outers from the Downtown Eastside (Vancouver’s drug slum.) There was follow-up community mental health care, again with flaws and hurdles, but not the “please go away; we don’t want to see you” Americ-ahole attitude you describe here. In Canada, the mentality was “We want to keep our citizens alive.”

    I reckon it’s even better Down Under (but I WOULD say that, because it’s been paying my salary for the past five years.) I’m an on-call nurse who’s worked at a heap of hospitals around Melbourne, community mental health centres, even on assessment teams who go to peoples’ homes when we get calls about folks in psychiatric distress. We can’t admit everybody to hospital. We can’t fix everybody, or make them all happy. But we TRY. Even amongst the most jaded of psychiatrists and cynical old nurses (in the public hospital system, we see a lot of unpleasant people, and everyone is judgmental, no matter how they might claim not to be) we’re not blatantly dismissive the way you depict so many staff you’ve encountered. It’s a cultural thing. Aussies, at least those of us in health care, have a mostly forgiving, egalitarian ethos when it comes to our mates in strife. We might not LIKE some drongos, borderlines and anti-socials, but we look after them as best we can. They get scripts, they get follow-up care at outpatient psych offices; we’ll make every attempt to chase you down at home to make sure you rock up for your appointments (or your depot anti-psychotic injection if you’re on an involuntary treatment order). In community settings, I’ve often done like a detective re: the latter, and I’m not even on the homeless outreach mental health program that deals with the city’s street people.

    In short, the two countries I’ve lived in with universal, government-run health care for EVERYBODY (not just old people like in the U.S.) would not treat humans the way you were treated. Life is the goal; not denial of service. On top of how The System is centred on treating people instead of rejecting them, there’s back-patting self-satisfaction in knowing that we medical types have tried to help. How do the SOBs who knocked you back live with themselves, knowing they stomped on someone who was having trouble? Rhetorical question — having a conscience is not a given in humans, even those who work in the medical field. It seems like cruelty and sociopathy are traits that are being selected for in Amerika’s recent cultural evolution. My thankfully abandoned land of birth is devouring itself from the inside, like a liver being dissolved by digestive juices from a blocked bile duct. Call it “pancreatit-U.S.”

    I’m sorry you can’t be here, mate. Good luck.

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  16. I worked in this broken system and (especially for the mentally ill) it is a crapshoot. After getting my Master’s in psychology I had to do a year of internship and found most people in the agency either didn’t know what they were doing. You might be surprised to know that some mental health workers actually have little education in their field. For instance, I knew of a person with a degree in computer science who decided to become a counselor. He took a short one year course (maybe online) to get a masters degree and it only required a 6 month internship. Most at least require 2 years and also require more undergraduate psychology courses but his didn’t. This is unusual, but shows you don’t always know what you’re getting.

    If I were mentally ill I would definitely try as healthy an organic diet as possible. There’s much evidence showing GMO foods that are heavily sprayed with glyphosate right before harvesting like wheat, corn, soybeans are killing the gut bacteria that aid our endocrine system in creating serotonin and others that have to do with mood and mental health. All the processed foods are becoming suspect. Other things that help are exercise (hopefully one you can enjoy), thinking positive, finding humor wherever you can and sunshine…beautiful warm healing sunshine with natural vitamin D.

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