Finding the the most suitable mental health treatment fit can be difficult; not only are therapists important to try on, so are facilities, programmes, and treatment centres.
I began outpatient mental health treatment, psychotherapy, and medication directly after coming home from upstate New York and discharge from the state hospital centre in Binghamton, New York. Shortly after arriving back home, I began treatment at a local hospital-based clinic. I started in the partial hospitalisation programme. From this programme, I completed the programme within the usual length of stay: two weeks.
My experience in the programme was pleasant enough; the staff was friendly and skilled, and I was moved through the programme quickly enough, making the progress I was after. Upon discharge from the partial programme, I was referred to the hospital’s outpatient mental health programme. There, I would do a seven-year stint with various therapists and psychiatrists over the better half of a decade of recovery.
During the initial phases of treatment, I made incredible gains. I had a motivating therapist and a shrewd psychiatrist. I was adherent to treatment, medication, and therapy. Don’t get me wrong, there were setbacks, but they were my learning moments. Eventually, I learned about my disorder, gathered insights, and some better judgement; and then I returned to the classroom after about a year. After three, years I began graduate school. Commuting from the hospital to obtain medication monthly was problematic only where traffic was concerned. I had a reasonable new psychiatrist who cooperated and supported the distance in treatment. After all, the waitlists up north in New York at the time and the length of my graduate programme – given my ultimate return home 0 didn’t make sense.
I fulfilled my end of the treatment bargain and returned home periodically for therapy and routine psychiatric monitoring. I was able to complete graduate school and remain connected to the hospital without any issues. After returning home and working as a social worker and practising in the community, I was assigned a new therapist and psychiatrist. Both were very much team players, but neither of them was on my team. Bi-monthly therapy appointments were littered with complaints about my attendance and speculations regarding my medication adherence. Given I was stable and working and living independently with supports in the area, I was baffled as to why I was under the radar of the treatment team at all times.
It seemed as if therapy and psychiatric monitoring were downright adversarial, and nobody heard my concerns about the quality and content of treatment. That was when my psychiatrist began to build an argument that I was starting to display signs of hypomania at the very moment I needed my stimulant titrated up. I was falling asleep on the road, sometimes while driving, and could not complete the workday without periodic naps.
At first, I explained to my psychiatrist that my combativeness (or rather, assertiveness in sessions), wasn’t due to mismanaged mood disorder; instead, I felt I was being stigmatised and misdiagnosed. Even worse, I was frustrated over the disarray of my treatment team’s lack of cohesion. I was stable for a long time, but as soon as I had a different idea on how I wanted my treatment to take its course, I was non-compliant and a problem. To make matters worse, my psychiatrist began playing around with my medication to justify her hypomania claims and lowered my prescription to the point where it interfered with my capacity to perform any work at all.
I requested an FMLA leave, which my employer was willing to be complicit. My psychiatrist at the clinic refused to sign off on my FMLA. She stated I was not in a crisis or acutely symptomatic (but hypomanic enough to lower my medication even further) because she didn’t like my tone or demeanor in session. At this point, I sought the help of the clinic director, who was familiar with my case and worked in the community. He was unwilling to do anything.
The supervisor wouldn’t change my psychiatrist or review her work to ensure my treatment wasn’t affected by her wanton dislike for me, and clear motives to have me discharged from the clinic where I was wouldn’t be her problem anymore. And indeed, after I complained with the director, the doctor’s tone changed again. Not only was she speaking with an accent and laboured speech, but she was so cold I felt I needed to bring in a family member into session.
I understand, in a mysterious unappreciative way, why the director pushed back on my request. ‘Mental patients’ can be demanding or have been characterised this way when they are symptomatic. They make special requests which can interfere with clinic operations. In my case, I was being made an example of, and I was not happy about it. When I communicated this to him, he understood why I felt the way I did. After all, the very act of complaining to him reinforced the stigma of the demanding mental patient. I was utterly justifying their portrait of my underlying mania by the very act of complaining.
In the end, I was told by my social worker, who was new and unfamiliar with my case, that if the doctor was not willing to sign my FMLA, I could admit myself to the hospital in hopes the inpatient workers in the hospital would complete the FMLA paperwork. I admitted myself to the hospital and was discharged within 24 hours, and referred back to a clinic/hospital-based mental health service. When I arrived at their E&R, I was taken into a room and told I was no longer welcome at the clinic and needed to go elsewhere for services.
No plan was in place for my ongoing injectable or oral meds. No appointment was put in place for me after this ‘discharge’ with another provider. As a result of this mismanaged care, I had to resign from my position at work, given I had no doctor to sign off on my FMLA and was discharged into the abyss. As bad as no treatment was, it reminded me of the importance of the early recognition of the signs a person may need to leave their clinic and find a new provider. If it doesn’t seem right, it’s probably not, and if you aren’t allowed to ask questions, go somewhere where you can.
Later that year, after connecting myself to another provider and hurling myself at their ER, I was reconnected back to outpatient treatment. I returned to the hospital that had discharged me to nowhere and requested to meet with the psychiatrist who supervised the programmes. He admitted, in no uncertain terms, the hospital was negligent in my care. He said I could complain to the county, in which they would get a write-up, but this wouldn’t amount to much but a slap on the wrist as he put it.
I find a few things troubling here. The medicalised nature of the FMLA does not fit or address the concerns of psychiatric disabilities well. It is black and white molded to address purely medical issues. Psychiatric issues are left at the whim of the psychiatrist, who has an ultimate say on if he or she will sign off. Given the ambiguousness of psychiatric disabilities, diagnosis, and someone’s mental status, I find it highly problematic I had to forfeit my rehab and respite, ultimately, my first career, because of an adversarial relationship with a provider.
Truly, treatment fit is critical, and allying with a therapist and psychiatrist can mean a significant difference in your treatment. But it shouldn’t be the be-all and end-all. Disagreements throughout therapy, medication, and other issues naturally arise during a mental health disorder. In this case, I was a licensed therapist, and clinical input tossed my input aside like clinical refuse. We need providers that take stock of their patients’ information if we are ever to rise to the level of patient-centred care.
Max E. Guttman, LCSW is a psychotherapist and owner of Recovery Now, a mental health private practice in New York City.
