Saturday, July 25, 2009

Manic Attorney Demands Psychiatric Treatment

Here's a harrowing and painfully personsal first-person account of struggles trying to obtain medical care in the United States. This was first published at DailyKos in 2006 and surely merits a second look now, in the context of the current battle to reform medical care market in the United States:

Manic Attorney Demands Psychiatric Treatment

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Sun Jun 04, 2006 at 10:11:54 AM PDT

"Of all the things I've lost, I miss my mind the most." I am a lawyer, but I don't practice law any longer; the struggle was too great. I'm manic depressive and have been most of my life. I had hoped I could overcome it. Now, I wish I hadn't done many of the things I did, but I can't take them back. If only I could've gotten psychiatric care earlier, I think things might have been different.

Beginning when I was eight years old, I had unpredictable fits of rage and cried in the closet, chanting "nobody likes me". At ten, I progressed to rages in which I broke out multiple windows of our house and threw dishes against the walls.

I knew there was something desperately wrong with me and I asked my mother - a college professor - to take me to a psychiatrist. But my mother's college's health insurance included only three visits per year for psychiatric help. With five children to feed, my mother had no money left in the weekly budget for payments to a psychiatrist.

My mother was a working professional with a home and a car, yet she was helpless to get her boy the psychiatric help he needed, so I was on my own and my problems progressed.

My father was an alcoholic with his own mental problems. Once, when I was five or six years old, he wrote with his own blood, "I got a job" on the wall of our bathroom. (His alcoholism and mental illness made it very hard for him to find and keep employment.)

But, I was recognized as a child prodigy. I started college when I was thirteen years old, attending classes alongside other students who assumed I must be four years older than I actually was.

I think I was ten years old when I first heard the words, "I want to kill myself" ringing over and over in my mind. Once, when I was eleven, I came "this close" to getting professional help, when my mother put the cost of care aside and took me and my brother to see a psychiatrist at a prominent children's hospital.

But, as my mother later explained to me, she simply didn't have the money for us to enter into weekly psychotherapy. So in spite of the horrors we had recounted to the psychiatrist, we just went right back home afterward to the same dysfunction.

By the time I was sixteen, I had a driver's license and my suicidality finally had an outlet. I began driving on the highway with my eyes closed, counting to ten to see what would happen. I was attempting suicide on a daily basis.

Quite understandably, no one wanted to ride with me. I knew I was a danger to myself and others. (In my now-ended driving career, I hit four cars from behind and intentionally caused countless accidents simply because I was depressed and I wanted to die.

I know I shouldn't have behaved this way, but I couldn't help it. All sorts of thoughts of self-hate would invade my head, and I just pushed the gas peddle down harder as the thoughts got worse. Finally, when I was be driving over a hundred miles an hour, I would be distracted enough to transform my self-hate into . . . what?

I had so many fantasies of killing myself: I would drive to New Hampshire and hang myself from a tree . . . In my mind, I built a guillotine in my backyard and was only prevented from severing my head by the curious and meddlesome neighbors. But, when I went to a psychiatrist's office with these thoughts, the first question was "What insurance do you have?"

Years later, I learned that Trazadone, the anti-depressant, miraculously relieved me of this compulsion to speed. Had I know this before, the roads could have been much safer much sooner.

I desperately wanted help. When I was 21, I found a clinic in B[xyxztp] that offered free psychiatric care, but I had to drive 60 miles to get there and 60 miles back, twice a week. Although the meetings relieved my desperation in a transitory way, it was a questionable trade-off for all the other drivers on the road. I think the whole State would have been safer had my town had good mental health care closer to my home.

At 22, I finally got a full-time job and had health insurance, but I still had to commute 70 miles per day to get back and forth to work. My work-based insurance covered less than half the cost of therapy and was exhausted after ten visits anyway, practically before the therapist knew my name and address. I also joined some anonymous programs and attended meetings between seven and fourteen times a week.

The only way I was able to work was to find therapists who would help me for less than their going rate and who would let me run a tab. (Sixteen years later, I still owe one of them almost a thousand dollars.)

I was struggling to keep afloat, so it took a while for me to consciously attempt suicide. I was 27 years old before I made a noose to hang myself and then swallowed a bottle of aspirin. By now, I was a college student with health insurance, so I could afford to attempt suicide. Afterward, I drove myself to a hospital emergency room. (Insanity is crazy!)

This, too, will sound crazy because it is: By the time I was 26, I had found just two things that could momentarily relieve my depression: (1) unrelenting sexual pursuits (otherwise known as "sex-addiction") and (2) a lofty and unattainable goal combined with my absolute determination to achieve it. By pursuing such goals assiduously, I learned the difference between what was "impossible" for me and what was "merely highly improbable". With a commitment to a long-term goal larger than my anguish, I had at least one reason not to end my life.

So, after graduating from college magna cum laude (which turned out to have been merely highly improbable but not impossible) I decided to go to law school. I hoped that I could nurture the side of me that wanted to help people while killing the side of me that wanted to self-destruct.

I think few people knew what I was going through. After I graduated from college, I worked in the governor's office, responding to constituent mail and proofreading executive orders. I wore a suit and wing tipped shoes. How could I be a lunatic?

It was very hard to achieve in that excruciatingly difficult first year of law school while my every waking moment was spent trying to seduce my female classmates and the women I met on the street. My motto then: "Anything worth doing is worth overdoing."

Somehow, I succeeded academically anyhow. I think that spending five weeks in a sex-addiction treatment center helped me to reassess my priorities. I realized that I would have to be crazy to value sex addiction more highly than I did my law school career. Talk about obsessive compulsive disorder!

For a full year, I abstained from all sex and even from talking to women so that I could get my life in order and focus on graduating from law school. It was my hardest year ever, during which even the most beautiful and available women were off limits to me. I had become convinced that even one slip might be my last.

My psychiatrist had me try various different medications to treat the depression I was in. One combination made me so sick that I had to stop one of my legal internships halfway through.

In spite of the emotional trouble I was in, the school health insurance provider had not wanted to pay for my hospitalization and each meeting with a psychiatrist had to carefully document the need for continued care.

At night, my mind raced with thoughts of the horrors that might befall me, so I prayed to God for a reason to live and a way out of my troubles. Only when the college's chief medical director called the HMO and said I was imminently suicidal did the company relent and pay for me to be hospitalized.

Even though I was a full-time student with a full scholarship and much federal aid, there was little mental health care available to me, unless I could pay for it. So, my mother cashed out the annuities she had been saving for my retirement, and I spent her life's savings on antidepressants and psychiatric care.

During law school, when I had access to college medical insurance and psychiatrists, I discovered after grueling experiments that Prozac chilled my depression while Trazadone (anti-anxiety, anti-depressant) miraculously made if possible for me to drive at the speed limit.

These two medications combined with therapy worked even where my own willpower and dozens of successive speeding tickets and license revocation had failed. And I graduated from law school!

I learned some other important lessons the hard way during this period. I discovered that trying to have sex with all women led only to repeated hospitalizations. And by working with a psychiatrist, I learned that graduating from law school was merely highly improbable. Things that are highly improbable for insane people (like graduating from college and holding a job) can often be achieved nonetheless, with diligent effort and adequate psychiatric resources.

I have also learned that, for a person who is manic depressive, the improbable can become possible, with twice-weekly psychiatric therapy sessions and an adequate medication regime.

After I passed the bar (another feat I was sure was impossible), I achieved a measure of success professionally. I had a small staff, began to teach, and the media began seeking out my expertise. I supplied newspapers with op-ed pieces and wrote articles for professional journals, mentoring law students and serving on professional committees. I maintained a public demeanor appropriate to my activities, and limited my insanity to my after-work hours, to the extent possible.

When I was depressed, sometimes I got very frustrated and swore in front of my clients and even their children. On other occasions when I won difficult cases, I still felt depressed and I cried in front of my clients, blaming my teary eyes on the cold wind and rain. I knew there was something desperately wrong with me and so did the close friends and colleagues in whom I confided.

When I started working as a lawyer, I hoped my access to healthcare would improve, but it didn't. It actually got worse. My employer's insurance did not cover psychiatric care, so I went to state-sponsored clinic. We met twice a week and since I couldn't afford the medication he prescribed, he sometimes provided manufacturer's samples. But just when my therapy was succeeding and I had spent months without wanting to kill myself, and had even passed the bar exam, the psychiatrist said I seemed healthy and didn't need his help anymore.

My boss thought I needed help, but that carries little weight in the current US health care regime. Employers pay for our health care the need to return employees to work healthy rarely takes as high a priority as saving the insurer's bottom line. I think the only reason so many psychiatrists helped me was that I spoke engagingly and even shockingly honestly about my own lunacy, but I also wanted desperately to get well. They saw my great potential and didn't want it to go to waste.

Sometimes when I most wanted to kill myself, I thought about the clients who needed my help. I reminded myself of the difficulty they would have finding another attorney with the same skill set and willingness to make the services available.

But, my psychiatrist's boss was leaning on him to treat patients who were more needy, instead of treating practicing lawyers. As the medical care vise tightened around me, it squeezed what little sanity I had achieved right had back out of my head.

I was hired by a reputable national organization and quickly promoted and moved to a new state, where I had intense new responsibilities and no established psychiatric care. I quickly became overwhelmed, so I discreetly inquired as to our company's health insurance benefits. And that's when my health insurance nightmare began again in earnest.

The employer had an HMO with severely limited number of providers who were listed in no particular order in a large telephone book. They literally just handed me this phone book when I told them I needed psychiatric care.

When I independently contacted the professionals to whom I was referred by friends and specialists, the answer was always the same: "I don't deal with HMOs; they're too much trouble and they pay too slowly." Psychiatrists charged $100.00 per hour, so I knew couldn't afford the two visits per week I needed to work successfully.

Ironically, while at work, I supervised a budget of over $12,000,000, with hundreds of clients and a dozen employees, yet after work hours I was medically destitute. I took calls from the New York Times and appeared on cable news by day, while at night I went to Home Depot for a rope to hang myself.

Still, I couldn't pay for good psychiatric help and my employer's HMO refused to pay. When they finally referred me to a psychiatric management agency, I believed I would be meeting with a psychiatrist who could evaluate my immediate need for medication. I was suicidal.

But after two meetings, I became suspicious of this "doctor" and insisted on knowing the therapist's credentials. Only then did I discover that he was not a medical doctor at all and could not prescribe medication at all. He was just a gatekeeper for the medical establishment, trying to dissuade me from getting treatment in order to save money for the HMO. He had no intention of referring me to a psychiatrist.

The fact that I was a practicing lawyer only heightened my humiliation since I was still powerless in the face of the capitalist medical bureaucracy. Certainly I could have paid for some care out-of-pocket, had only I been willing to surrender all of the disposable income that had attracted me to the law profession in the first place.

During this period, I organized and drove a group to Washington to lobby on a piece of legislation. But I felt so depressed the whole way that I kept imagining causing a head-on collision, which seemed the only way my emotional nightmare could end.

Unable to affordably access the care that had helped stabilize me in the past, I was depressed and suicidal again. I even talked to a minister, but he told me to see a psychiatrist.

Soon, I lost my job and spent the rest of my savings on $100.00 per visit psychiatric visits and medication. My student loans fell into default. When my money ran out and the therapy visits stopped, I alternated between hiding in my house and driving on the expressway at 105 miles per hour in the breakdown lane. (I well remember my velocity because it was the maximum my new Honda would do while traveling downhill.)

I had four auto accidents during this period, involving seven other people, and all caused by my own wanton suicidality. It's a miracle that no one was hurt or killed in those accidents.

In our mental health market, you must have mental health to get mental health care. The very mental disability that drives one insane also makes it hard to keep a job or stay in school and thereby maintain health insurance. So, when you're depressed, can't work, and need help the most, you are least able to get it.

With all other avenues seeming closed to me, I decided to move - to France. I reasoned that if my mind could do nothing else successfully, at least I could learn another language, for all the good that might do. I applied for a passport and began to study French.

But, meanwhile my driving and suidality made an imminent "danger to myself and others", so I went to a hospital emergency ward and demanded to be admitted. I was intensely confused and sleepless, but without health insurance, I was quickly released and was on my own again.

Then, I found a really good therapist and psychopharmacologist who seemed able to help me, but only if I payed them a total of $1,000 per month. I did until my money ran out, and then I got on the highway to drive my pain away, weaving in and out of traffic in an unsuccessful campaign to kill myself.

A few months later I was working again, but at half the pay. One day, when I was taking the day off to have my car serviced, I proceeded to the City Clerk's office to request a gun license. I had decided to shoot myself in the head and quiet my demons once and for all. Yet, a question on the form about past hospitalizations stopped me cold: If I lied on this form and did NOT subsequently kill myself, might I be still be prosecuted and so lose my license to practice law? I could not rely upon myself to die, so I had to consider the possibility that I might live.

I walked across the street to a doctor's office and asked for their help instead, sharing with a therapist that the last remaining single remaining interest in my life was to go to France and learn French.

With all alternatives exhausted, she encouraged me to get going, insisting that I return to her office in a week with an action plan. (I love directive therapists! Anyway, this was one plan I could implement before my therapy budget ran out.)

I knew that simply moving to the French Mediterranean would not cure my depression permanently, but at least it gave me a short-term goal and a plan. At the time, any distraction from my inner turmoil seemed reasonable in comparison.

To live in France, I would need a visa status. So, although I had never taken a course in French and I spoke no French at all, I applied for a student visa and enrolled in a French doctoral program for international law. What better way to immerse myself in French culture? Plus, enrolling in a doctoral program helped me to explain leaving my latest lawyer position after only two months on the job.

Surprisingly, the move made an immensely positive difference in terms of my access to medical care. Even as a foreign student, for just two hundred dollars I was able to enroll for a year in the French national health care system. How very ironic it was to receive medical treatment overseas for free that I could not obtain in the US even as working attorney.

Although I had been denied Medicaid in the United States after I lost my job, I had a French Carte Vital within a month. This universal health card assured that doctors, hospitals and pharmacies nationwide would provide me the help I needed. (Except, ironically, the American Hospital in Paris, which doesn't accept government reimbursements.)

In France, I was finally diagnosed as manic depressive, bipolar. In France, medical diseases that are particularly severe are covered for all necessary treatments at all hospitals and with no co-payments. Since manic depression is defined by the government as a "particularly serious disorder", all of my associated costs were covered 100%. In France.

My psychiatrist treated me twice weekly without ever asking me for payment. We tried a number of medications without the fear that the one I most needed might be beyond my financial means. I tried lithium for the first time, but it didn't work for me. Still, I felt much less desperate knowing that I would always be financially able to see my psychiatrist and take the medications he prescribed.

The most difficult part of fleeing to France was foregoing the practice of law. I wanted so desperately to live the middle-class ethos of consistent work and respectability. Yet I finally accepted that pretending to be sane was more work that I was able to do. Although I had managed to render service to my clients and make a professional mark, yet the emotional burden was more than I could continue to carry.

Because of effective and consistent treatment or for whatever reason, I never had a car accident in France and never received a speeding ticket. But, as the war in Iraq drove up the US deficit and drove down the value of the dollar, I found I couldn't afford to live in France anymore. I couldn't work and I sometimes had no food to eat beyond a croissant and a glass of orange juice. I found myself living in poverty, unable to pay even my most pressing bills. The desperation and anger came back and I didn't know what to do.

I came back to the United States and tried to apply for Medicaid, but after submitting ten times as much paperwork as had been required for success in France, I was rejected in the US as having too much income, even though I was living at the poverty line.

Today, I've made what peace with all of this that I can make. I live in one of those third world countries where the dollar goes further. Although there is no national health care here, the very same medications that cost $200.00 per month in the United States are available here for just $30.00 dollars per month, which is seven times less.

Today, I still can't afford psychiatric help. But I'm happily married, the weather is warm, the food is good, and psychiatric intervention hardly seems as necessary anymore. I have all of the daily challenges I did when I was a practicing lawyer.

I don't drive anymore, so now the world is a much safer place for me and everyone else. I wish I had never been as insane as I was.

Sometimes I wonder if I could return home to the United States and practice law if necessary. But, I know I couldn't work and succeed in the US without consistent psychiatric help and medication, and I know those won't be available in the US until there's a program of national health care. Since providing health care to all Americans is considered "communist" and anathema to the American spirit of individualism, I have little hope of ever returning home, and many readers might think that's just as well.

Sometimes I'm horrified to think how many psychiatrically ill people just like me are locked away in prisons because the chances they took turned out turned out worse. How many suicides, broken families and addictions might have been prevented if doctors asked "what help do you need?" instead of "how much money do you have"?

I can't pay my student loans. I may never again formally use my $150,000 legal education for which my mother and other contributors paid so dearly, but at least I won't drive from doctor to doctor, searching desperately for affordable psychiatric treatment.

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