Tuesday, 18 July 2017

Being Difficult

When my son was born, a simple administrative error on the part of the insurance company (they temporarily gave him the "wrong" gender) meant that the hospital did not get immediately reimbursed for the costs of the birth. American healthcare companies are expert at extracting money from patients. Even when the error had been resolved and the insurance company was in the process of paying, we received a quick succession of increasingly threatening letters for a sum that would have been ruinous to almost anyone, let alone two graduate students. When the letters started to include indicatinons that they were from a debt collection agency, I called the hospital billing department. I didn't intend to be particularly pushy, but the conversation took a turn toward the perverse. I was told that they had not forwarded the claim to a debt collection agency, and that I shouldn't worry. I felt like I was being gaslighted. I was holding a letter that said, in caps, that it was sent by a debt collection agency. I pointed this out. Again the agent asserted that the case had not been forwarded. Someone's vision of reality was under threat, and I wasn't about to relinquish mine. I got...shirty. I raised my voice, I told the agent that I felt like I was in Alice in Wonderland.

I don't feel proud of telephone rudeness, but I don't feel ashamed either. This is unusual; I am a person who is prone to deep bouts of shame. I think everyone needs to be difficult sometimes. When dealing with large organizations it is often unavoidable. We are under pressure, faced with an unsympathetic or belligerent representative, or just with a good old fashioned jobsworth. A bit of assertion greases the wheels. A but too much assertion can really get the job done. 

So being difficult is something we tolerate. It feels like an allowance to be spent under certain conditions. But in mental healthcare the allowance is far smaller. Recently I have had several experiences in which patients have spending some of this allowance, and it has come back to bite them. It's not
 my place to share the details, but suffice it to say that they include more or less reasonable assertiveness, some fragile professional egos, and a healthcare system that is far less used to regular pushback from users. They have made me think. If I had been a psychiatric patient my pushiness around the billing might have been more readily shrugged off.

In mental health care, the users of services tend to get pushed around a lot more than in other systems. They are typically more likely to be used to being treated this way by professionals. If they aren't, then learned passivity is one adaptive response. It is rare for a mental health professional to have to explain themselves in plain English, or to give reasons for a decision. Their word so usually goes, and when it is questioned they are tempted to describe someone as being oppositional, even Borderline.We should be energetically resisting this tendency for all we are worth.

Yes there are people who need more effective ways to problem solve.If difficult is all you can ever be, you soon find out that it stops working for you. Something useful for a sympathetic outsider to do is to flag such tendencies in a way that you can recognize, and even help look for alternatives. This might be one of the best uses of psychotherapy. 

But often the soul-searching is on the professional. We don't ask often enough why our decisions have resulted in anger or distress. Sometimes the reasons are subtle and complex. It is reasonable not to have realized, but we really should learn. Sometimes the answer is more obvious and our failure is staggering. At their best healthcare systems can be infuriatingly counterintuitive. At their worst they are absuive. Staff have a duty to acknowledge this and to not be part of the problem.

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