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 so 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 cannot 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 (and yes, as you’re now aware, I don’t have any prescriptions either) 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, and while the death of the author etc., please do not worry, I’m fine.) I just wish it, 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.

Extremely Abbreviated Description of One Female’s Pain

1

Last year, a doctor’s aide took my vitals. I sat at ease in a chair, until she told me matter-of-factly that my heart was beating fast enough to warrant a trip to the emergency room.

Had I exerted myself before going to the doctor, she wanted to know. I hadn’t. The hospital where this doctor was located was out of the way, inaccessible by public transit, so I’d taken an uber to the front door. I’d even taken the elevator to the neurology clinic, shamefully choosing not to walk the two flights of stairs from the main entrance.

“No,” I responded.

“You’re lucky we caught this. I’ll have the doctor talk to you right away.”

2

The only reason anyone caught my heart abnormality was because of my headaches. They’re migraines, technically. I’ve always gotten them, at least since I was a little kid. I’d long ago given up on doing anything about them. But after I had one so bad that I fainted and wound up in the hospital with a skull fracture, I was forced to go through the motions of seeking the cause of the pain. I soon gave up on finding the cause – rather, my doctors soon gave up. So I sought medications that might at least relieve the pain. That’s why I was at a neurology clinic getting my vitals checked.

It feels tired to write about being a woman with headaches, but that doesn’t make it any less true. And it is tiring to be a woman with headaches. I am tired of it.

3

I write too often about fracturing my skull. I reference it compulsively. Only when reading Leslie Jamison’s essay on female pain did I admit to myself why. Jamison quotes from a memoir by Lucy Grealy, a woman who had childhood cancer and whose face was disfigured by it, cause for the title of Grealy’s book: Autobiography of a Face. In it, Grealy writes, “I was excited by the idea that something really was wrong with me.”

“Grealy had been craving the identity-locus of damage even before it happened to her; and was happy, as a little girl, when trauma first arrived,” writes Jamison.

For the first few days in the hospital after fracturing my skull, I was torn between fear of dying and self-pity. These are related feelings: self-pity follows from awareness that one is too young to experience fear of dying, and this acknowledgement often strengthens that fear, goading a person to think of all that she will miss should she die.

For me, this manifested as yelling deliriously at a nurse. “You don’t understand, I can’t have a head injury!” I screamed, trying to keep her in my field of vision despite being strapped into a too large neckbrace, which forced me to look straight up at the white ceiling if I wanted to minimize the cutting pain the brace caused as it sliced into my too small, too thin collarbone.

“I finally have a job where I need my brain” I yelled, no longer able to see her.

When the nurse reappeared in my line of vision, I told her to let me check myself out of the emergency room. If I left, I reasoned, the injury would cease to exist. If I was someone not in a hospital, I would no longer be someone who needed to be in a hospital.

I lost consciousness before I could hear her response. Maybe she didn’t respond at all.

I soon acclimated to my new existence as someone confined to a hospital bed, someone who understood how to use a bedpan and who no longer cringed at the needle stuck into her arm every four hours by a blurry amalgam of nurses, made indistinguishable in the darkness of late sterile nights when she, or he, woke me from sleep to prick me for another blood sample. A new feeling came over me, not unconnected to fear or dying or self-pity, but distinct: I felt grateful. Something very bad had happened to me, something no one could deny was terrible. I had a traumatic brain injury. I might not recover. The doctors told me I had a brain hemorrhage. They told me that my spinal fluid could flood the space between my spinal cord and my skull, and that this could kill me.

I did not cease to fear for my life, or wish I hadn’t gotten hurt. But given that I had, I felt precisely what Grealy felt. I was excited by the idea that something really was wrong with me.

4

I know better than that. I know I should be what Jamison calls a “post-wounded” woman. “Post-wounded women know that postures of pain play into limited and outmoded conceptions of womanhood,” she writes, and it’s true.  I fear my parents will read this essay and misunderstand me. That they’ll be hurt, or horrified, because they haven’t read Jamison’s essay, or think my excitement about being an authentically unwell, tragic woman compares in magnitude to my resentment and self-pity about my health. It doesn’t.

And yet…

And yet, I have a new wound; one I could be accused of choosing to prolong for the sake of pity. Ever since fracturing my skull, I’ve become paralyzed at the thought of making an appointment with a new doctor, or keeping up with the old.

I managed it for a year or two. I saw the neurologist, who gave me three different sets of pills for my headaches. I saw the ENT specialist, who explained to me that while I might never get my sense of smell back – a loss that came from a piece of my skull slicing through the nerve endings that translate odor into scent – I might. He wouldn’t say anything more definitive, surely fearing litigation. I saw a therapist, who saw a young woman so wounded as to be unfixable, so she gave me some pills, and I stopped seeing her.  I saw a specialist who was supposed to tell me why I felt dehydrated all the time, which, combined with the migraine, had caused me to faint in the first place. He cut open my lip and sewed it together again, testing for Sjogren’s Syndrome, an autoimmune disorder that was the only explanation he could think of for my dehydration. I can still feel the stitches through my face. When he told me I’d tested negative, I saw someone else, who gave me pills to take three times a day, pills meant to stimulate saliva so my teeth wouldn’t decay, the enamel eroding and rotting the bone at an accelerated rate. I saw a dentist, who saw a thin girl with no enamel left on her teeth. “Are you bulimic,” she asked, adding that repeated exposure to stomach acid erodes one’s teeth. Even when I explained my condition, she seemed to still see a bulimic. I saw my new primary care physician, who helped me coordinate all these doctors, until she didn’t.

So now, I see no one. For the most part, this is okay. But when it comes to the heart abnormality the neurologist found, I never saw a cardiologist. It was over a year ago. I can’t seem to make myself schedule an appointment. When an ex saw me continue putting off the call that could have gotten me an appointment, he first tried to help. Then he gave up. We broke up, with him telling me to “see the doctors already, I don’t understand what is so hard about that.” I told him I would.

When I told the guy I see – “I wouldn’t call us ‘dating,'” he once told me, so I don’t – that it’s been over a year since a nurse discovered my heart abnormality, he told me I should see the doctor. I didn’t respond.

Jamison would probably add me to her cases of women dwelling in woundedness. She would be right. But I’d add – and so would she – that it’s more complicated than that.


Note: I’ll incorporate this essay into a longer piece elsewhere, but I wanted to share it as is in the meantime.