Wednesday, June 20, 2007


A lot of my patients are chronic manipulators of the system. This really torques people off, especially the poorly-paid line staff. Yet our manipulators are irritating mostly because they aren’t very good at it. Good manipulators pass unnoticed.

I have a 30ish woman who is on probation, but will not allow us to contact her PO. She knows she will be facing 7.5 – 15 if too many more probations violations show up on her sheet, so it’s rather a roll of the dice for her. Or rather, like a giant game of Jenga against herself, in which she is oddly compelled to keep removing sticks as carefully as she can, rather than adopt the obvious solution of not playing at all. One more restraining order; one more overdose; one more loud disturbance; unable to stop.

She is costing the State of NH a fortune. Lots of Medicaid care, rental assistance, mental health and probation services, and now $800/day in a psychiatric hospital. Yet she sees almost none of it herself. She wants to be cared for (but independent, like a permanent 16 year old) and so gets herself into a hospital with an uncomfortable bed, unexciting food, little entertainment, and dangerous peers. We are paying for a first class vacation on an island paradise for her and her 12 closest friends, but she is receiving life in a mediocre boarding house. If she were an effective manipulator, she would get a bigger cut, wouldn’t she?

Much of this stems from receiving expensive services she doesn’t need: 24-hour nursing care, multiple MD’s, psychologists, rehab therapists. But once she’s here, we have to provide those things. We would be considered neglectful if she had a medical complaint – any medical complaint – that we failed to address. If she decides she wants to throw a chair because she’s angry, then the State of NH pays someone to talk with her in a firm but therapeutic manner, directing her to consider consequences and make predictions about others’ likely responses, coaching on “using her skills” to reduce her anxiety, and getting hit and injured when she decides to throw the chair anyway. The people providing this expensive service to her get paid 2 – 2.5x as much as she does to be sick.

We often wish there were some way to just short-circuit this system. If we could pay her to stay out of the hospital we’d save a bundle and she’d make a bundle. But then lots of other people would want the same deal, and we’d either have to pay everyone who signed up or hire expensive people to determine whose claims were legitimate. Plus people to train and supervise them to make sure they aren’t being corrupt or unethical. Plus people to oversee the bureaucracy that contains these people, to make sure that the buildings are safe and the sexual harassment workshops are attended.

It’s a shame for everyone involved: patient, staff, other agencies, taxpayers.


Jerub-Baal said...

I'm a layman, so forgive my ignorance in this. My understanding of medical ethics is that providers can (and may be construed to have an obligation to) violate patient confidentiality if the patient is a threat to themselves or to others.

Again, as a layman, I wonder why possible parole violations wouldn't fall under that. Under what possible system of thought would you be prevented from accessing her records, finding the PO officer, and simply dropping the file in his or her lap?

Oh, wait... you work for the State....

Never mind...

Anonymous said...

My autistic plus daughter is more successful, though it took her a decade and a half. She now lives in her own place with a compliant companion 24/7 and somebody to take her out once a day for paper and coffee. She sits in the hot tub when she wants and bangs on the bird cage when she wants.
First she had to go through several of our efforts to get her a job. When she found out what she had to do to get fired, she did it. So now she is a lady of leisure indulging her obsessions when she feels like it. She is relaxed and happy now. BUT, where would she be if she didn't have us to back her up and buy her the duplex and found Autism Community Services and petition the legislature for person-centered accommodations and hire the companion and fill out paperwork for the county and hire a trainer to discuss how behaviour is communication for those who can't talk and SSI and and and?