This is a composite of several
stories, but the details are absolutely true, and far too common.
A woman contacted us a while ago to get some follow-up care for
her adolescent daughter, who was being discharged from a psychiatric
hospital after a bizarre runaway episode. But let's focus now on
the mother, not the child.
Sheila is a witty, sensitive,
intelligent woman in her 30s. If she were your neighbor you would
like her. She works hard, pays her bills, in general is an upstanding
citizen. She is a single mother, having been divorced from her husband
a few years ago.
She is the daughter of alcoholic
parents. Her father was physically and emotionally abusive to her;
Sheila was beaten frequently, and made to feel that she was ugly,
bad, useless, incompetent, and to blame for all the family problems.
You would not have known any of this if you lived next door to them.
The family was successful economically, liked and respected in the
community. Sheila got out of the home as soon as she could by jumping
into marriage with the first man who asked her.
But by the time their first
child was born, Sheila's husband had begun beating her. She became
an example of this cycle of abuse, which is hard to understand but
is seen a lot, where women who have been abused as children find
themselves in abusive marriages. She put up with it for a few years,
then got away with her daughter She made good use of women's services,
and seemed to land on her feet.
Now here she is at our door
with her out of control daughter. As we explore, we find that not
only does daughter run away from home repeatedly, but she is defiant,
belligerent, and physically aggressive toward her mother. Sheila
is intimidated and feels helpless. In fact, she has a major depression;
she can't sleep, doesn't eat right, feels hopeless, guilty, and
ashamed all the time, can't concentrate, has thoughts of suicide--all
the symptoms. She is surprised to hear that, from our point of view,
she has an illness; her state feels normal to her. But this is frequently
the case with major depression--despite being more costly to our
society than heart disease or AIDS, it's a disease that often goes
unrecognized, even by those who have it.
So here we are: abused by her
father, her husband, now by her child. Our patient is aware of the
irony; it's another stick she beats herself up with. "Why can't
I just snap out of it?" she asks. "Why can't I just take charge
of my life?" Our answer - that she has a disease called depression
which she can't cure by herself - doesn't entirely satisfy her.
Too much of our society believes that depression is a sign of moral
weakness or lack of character - including most of those who suffer
with the disease.
This is another aspect to Sheila's
problems. Imagine that every time you went to the doctor you were
made to feel guilty. Imagine that we as a society assumed that there
is a state called "health" which is "normal"; that being ill is
deviant, weak, shameful, or your own fault. Because that is exactly
how Sheila, and in fact all our patients, are made to feel. Wouldn't
it be crazy if you had to feel that if you caught pneumonia, or
broke a leg, or developed a degenerative disease, that you were
somehow to blame for your own trouble? Isn't it crazy now that people
with depression, or post-traumatic stress disorder, or schizophrenia,
have to feel that way?
Now let's ask: how does Sheila
pay for getting the help she needs?
First of all, it's necessary
to recognize that she has to pay for it. We get a state grant that
helps us pay for services to her children, but there is no state
grant for adult mental health services. If Sheila had a substance
abuse problem, or were chronically mentally ill, there would also
be state funds to help her out. States are cutting back on subsidies
for people with acute mental health needs, who are dismissed as
"the worried well." So Sheila's on her own.
Now, Sheila's employer is using
a managed care plan. This means they will reimburse us following
their usual practice for mental health services: 50 percent of the
cost of each office visit, to a maximum of $1000/year. This is a
rather standard benefit plan. At our commercial rate of $120/hour
for individual psychotherapy, they will pay $60 per visit. At that
rate her benefits for the year are exhausted after 17 treatment
hours, four months of once-a-week treatment. Plus, she's expected
to pay the co-pay of $60 per visit.
Think about this for a minute.
Suppose you had cancer and required regular chemotherapy, or kidney
disease and required dialysis, or pulmonary disease and required
oxygen and physical therapy; or that you had Lyme disease and needed
visiting nurses and IV antibiotics; or that your child had an accident
and required surgery--what would happen if there were an annual
cap on benefits for these conditions? What would happen if there
were a copay of 50% on these benefits? You know what would happen--there'd
be a revolution. But we seem to take it for granted that there should
be caps and copays on mental health services--remember what I said
about being made to feel that you are to blame for your own disease?
We work out a plan with Sheila
where she will come for psychotherapy every other week, and attend
our free self-help group on depression. She will pay us our minimum
fee out of pocket, and we'll accept what her insurance pays us.
We'll continue to treat her after her insurance benefits are exhausted.
We would prefer that she be seen weekly until she's better, but
she doesn't want to do that, even when we offer to reduce her fee
further. In addition, she sees our psychiatrist about every other
month. Her medication costs $8 a day--$3000 a year--thank god her
insurance only requires a copay of $10 on each prescription. She
makes about $15 an hour on her job--that's a gross of $30,000/year--could
anyone expect her to pay 10 percent of her gross for medication?
Sheila will pay us about $900
per year for her counseling, and her insurance will pay us another
$1000. It will cost us something like $3800 to provide her with
the group weekly and individual counseling every other week and
her psychiatrist visit at our cost/hour of about $45. We do our
best to be efficient and cost-effective, but realistically Sheila
will require perhaps a year or two of professional help before she
can recover.
Sheila is very fortunate to
live in a community that makes it possible for a clinic like ours
to come up with the $1900 in additional funds that it will take
to help get her back on her feet. Most people in the U.S. don't
have that kind of resource.
But I'm tired of organizing
fundraisers, coaxing our board members to ask their friends for
contributions, and going hat in hand to the United Way, year after
year. They're all tired of hearing from me, too. Isn't it time we
face up to the problem? Can anyone provide an argument on any ground
- economic, moral, therapeutic - to explain why we don't embrace
Sheila's problems as part of the social contract? Even in the crassest
financial terms, it just makes sense to help keep Sheila working
so that she continues to pay into Social Security rather than draw
on it, help her function as a mother to keep her daughter in school
and out of trouble and the hospital again.
How did we get into a situation
where "parity" is even a subject of discussion?