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There's a petition going around on this site asking President Obama to use his political capital to insist on starting a serious discussion about gun control. I've signed it. I'm glad to see it there. I consider myself a moderate on gun control issues for many reasons, but the current arrangement is the worst of both worlds -- we neither have protection from people obtaining rapid-fire weapons without solid proof of sanity and competent handling, nor the protection which might come from knowing that those people who have legally obtained weapons probably are sane and competent, and therefore can be trusted to use them for society's protection, not its destruction. We need to even out both ends of that spectrum, and a national discussion starting at the top is the place to begin.

But I'm not going there in this diary. I want to talk about the other national discussion we need to have. The one about the health care system and its role in allowing neglected patients to develop into mass killers.

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You may have seen this: the article by a mother of a thirteen-year-old with dangerous psychiatric issues. ""No one wants to send a 13-year old genius who loves Harry Potter and his snuggle animal collection to jail," it says bluntly. "But our society, with its stigma on mental illness and its broken healthcare system, does not provide us with other options."

I saw it, and it was what drove me to write this, my first diary ever, though I've been a member of this site for several years. I know too many people who have fought to get treatment for their own illnesses or their family members', from a system which is designed deliberately to make it as difficult as possible to get care for chronic medical problems of any kind. I've done it myself, though not within the psychiatric system -- my own chronic illness is fibromyalgia, a physical ailment, but one which illustrates the point nicely, so I'll use it as an example of how the system works when it does work, and then get into why it breaks down completely when used for dangerous psychiatric illnesses.

The American health care system rations its care by self-selection. It's designed to make it as difficult, unpleasant, time-consuming and annoying as possible to obtain medical care. This is not accidental. It's done in order to persuade people with relatively minor problems to self-select out of the system. If it's not worth it to you to jump through the hoops (goes the theory, perpetrated by doctors and hospitals whose schedules are packed, and insurance companies which don't want to spend the money unless unavoidable), then you probably don't need the help all that much. So, in order to obtain care, you are expected to go online, fill out a form for an appointment, make sure your records are transferred if you haven't seen that doctor before, get a referral from a 'gatekeeper' primary care physician, wait until your appointment date, call your insurance company in the meantime to get preauthorization, go in during business hours, bring your insurance card, fill out a large packet of forms, and wait until you're called, 45 minutes after your appointment time, to be seen for 15 minutes and handed a prescription. Which you then have to take to a different place (your pharmacy), which also has to be prearranged in advance, with forms to fill out and insurance cards to show, and drop it off, and wait for an hour or come back on yet another occasion, while the pharmacist gets authorization from your insurance company and counts out your pills.

That's for a simple matter. For someone with a chronic problem, it can quickly become an endless carousel of different specialists who need to be coordinated with each other, and authorized, and referred, and all the rest. Some of it is genuinely necessary to make sure that your care is actually what you need, but a lot of it is for the express purpose of hoping you will jump off the carousel. Because there isn't enough time and money to go around, and if you jump off; if you don't bother to get treatment, then the doctors have more time for someone who doesn't, and the insurance companies have more money to pay bonuses to their executives. It's a harsh system, but it does actually work to an extent, in that most people actually will go through all the rigmarole for a desperate problem while deciding it isn't worth the bother for a minor one which they can probably clear up at home. The issues we've seen with health care injustice in the broader spectrum largely come from breakdowns in the process when money gets too heavily involved... either because the wealthy are capable of pre-empting the process by paying to circumvent the hoops or have someone else do their jumping for them, or because the poor simply can't jump through those hoops even in a desperate situation -- can't take the time off work without losing their jobs; can't pay for insurance in the first place, leaving them without the opportunity to get care by jumping through an insurance company's hoops when they need it, etc. The Affordable Care Act is a long way from solving those problems, but it is at least a start.

But the other place the system breaks down is when it comes to illnesses which make it impossible to jump through the hoops, or impossible to make a reasoned judgment that it's worth it. And that is why we can't afford to use this system for mental health care.  Because one of the most common symptoms of certain kinds of mental illness is treatment resistance (Kay Redfield Jamison's work on medication resistance in bipolar disorder is excellent as an example). It's difficult enough for many psychiatric patients to accept help, even if the system were to make it easier. It's impossible even if they want it, when they are faced with a system of hurdles designed to reinforce everything in the human brain that urges giving up and staying home.

Nor can we blithely say, as our society seems to with physical illnesses such as mine (which includes energy issues that make it exceptionally difficult to navigate those same hurdles) that if they opt out of the system and can't access treatment, the only person they're hurting is themself. For most patients, it probably is. But for some, such as the little boy in the article I cited, it may not be. And if he can't get help as a child with parents who are strong, smart, educated, and committed to protecting their son and the world from his illness, what possible hope does he have when he becomes a young man? He will be an adult, legally entitled to make his own decisions; if his family tries to force him to get help then, he can and quite possibly will cut ties with them. The next they'll see of him may be a news story about the weeping parents at the school where he took a gun and killed another group of kids and teachers before he died.

We can't afford to put hurdles in the way of patients who want to fight their own demons, nor in the way of families who want to help them do so. We already have enough unavoidable difficulties in handling such disorders -- the violent psychoses are among the least understood of the mental illnesses, which are still, in turn, among the least understood of all illness. This is partly because the stigma has made it difficult to study, and partly because brains are complex creations, and we're only just starting to understand them.

But at very least, we need to stop putting extra hurdles in their way. We don't need to encourage them to opt out of the health care system. We need to do everything in our power to make it possible for them to opt into it. The deinstitutionalization movement had its advantages and its disadvantages for the mentally ill, but what was done to destroy the community care available afterward, in the wake of austerity budgets, made it unsustainable. If we're not going to offer long-term inpatient care for the sometimes-dangerous, we will need to recommit to offering real care and supervision within the community... that can't be taken away by the next budget cuts. We will need to put money into offering incentives that lead researchers and clinicians into mental health work instead of more-currently-lucrative fields of medicine.

And we will need to stop allowing the health care industry to do its triage by annoying clients into dropping out of care, at least in the mental health field, and look instead at how we can make it as simple, streamlined, and welcoming a process as possible to obtain care for the kind of illnesses which society wants treated more than the patients themselves may want treated. As easy and welcoming as walking into the gun store.

Extended (Optional)

Originally posted to PocketNaomi on Sun Dec 16, 2012 at 02:58 PM PST.

Also republished by Community Spotlight.

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