Several evenings ago, I spoke to a friend who is a new attending at an out-patient psychiatry clinic associated with a major east coast medical school. She told me that she conducted an initial screening of a man who was a walk-in to the clinic, checked the schedule, and gave him an intake appointment with the first available resident the following week. She then went on a scheduled trip to Europe and returned approximately six weeks later. Upon returning, she was told that the patient, with whom she had spent approximately 30 minutes, had committed suicide. She was referred to an affiliated psychiatrist to "process" the event, and attended 2 group therapy sessions for clinicians with a similar experience. For her part, she could not even remember the patient. Now, I do not report this because it is ironic - and I struggled not to say absurd - but rather to contrast what happens when you are affiliated with funding. If you have access to funding, you can, apparently "err" on the side of well... what's right. And on one of the saddest days of my life, as I was writing case notes after a group therapy session, a colleague came in and told me that the Medical Examiner's office had just called to inform us that a patient of mine was found in a hotel room, having completed suicide. They connected him to us by a prescription bottle they found with him.

Because I have the reputation of working with a specific patient "demographic," I will get calls that usually begin with, "Hey, I have this wo/man who lost his/her insurance and can't continue at this clinic..." Hey, always good to hear from you too. Right. Nevertheless, a patient who has actually had commercial health insurance, in my experience, presents with some significant "protective factors" personally, and "advantages" administratively. Paradoxically, in my experience, these patients nearly always result in administrative conflict, probably because they can be incorporated into treatment in a expedited process (i.e. disrupting the protocol).

I find that patients who have actually had health insurance tend to be in a better state of over-all health, generally, than the typical off-the-street public clinic patients. Secondly, they generally are "well-documented," preceded by a medical chart that sometimes includes an accurate medication & medical history, and sometimes (sorry) a psycho-social assessment conduct by a reliable clinician. Oorah.

And so, the patient in question here came to me because he had been laid off from, "not just a job, but my vocation," based solely on "seniority." In fact, he was a much-valued, well-acknowledged, and well-compensated employee. He had a significant history of a moderate major depression; a history of both child physical & sexual abuse; was in recovery from alcoholism - extended & continuous; and was acting-out sexually to the point of "devoting" hours each & every day to cruising his gym, a bathhouse, and Craig's List for "hook-ups." His affect was markedly depressed & anxious, but he reported his mood as "a little depressed, but hopeful." I will forgo detailing our actual work together. When he did not appear for his scheduled appointment - the first ever - I called, and we rescheduled for the next day. The next day, when he neither showed nor called, I again called, & when I got his voicemail, expressed my concern, asked him to call me immediately, and re-enforced a point in our treatment contract: no attempting self-harm or suicide without first calling me, 911, or the Emergency Psychiatric Unit. He had checked into a nice hotel that afternoon, and the Medical Examiner estimated that he died early Sunday morning.

No one in clinic, from the Program Manger to the supportive staff, said anything to me; everyone was gone by the time I had completed my notes and returned the charts. No one. I locked the place up & went home. If you are a clinician & reading this, it is my sincerest hope that this never, ever happens to you. I spent the entire night scrutinizing, me. What did I do wrong? What did I miss? I poured over my notes from beginning to end; attempted to "recall" the specific details of every session described. WHY? By morning, I was overwhelmed. I sat through the staff meeting, and the suicide was never even mentioned. When enough was enough, I simply stated, "I am devastated, and I going to our "Employee Assistance Program" (EOP). Perhaps POTFP could explain such programs, as he is truly a pioneer & expert regarding the topic (and be sure to click over there regardless) - but one aspect of an EAP is to be a confidential (even to your employer) source of referral assistance for situations like I have described. I can say that my perception was that the sponsoring organization of my clinic - who didn't really advertize the availability of the EOP (alright, they never mentioned it after the initial hiring session) - pretty much resented paying for 6 "free" therapy sessions. Now go back & read the opening to this post... All said, may he rest in peace.

I generally experience the term "minority" as a pejorative, often "masking" term for disdain. There are, however, times when I could not be paid to abandon my "vilification." Microsoft, according to surveys, took an old-fashioned ass-kickng at the hand of Apple's "I'm a Mac, I'm a PC" advertizing campaign. Somehow thinking it wise to retaliate, MS has embarked on a campaign of corporate dis'. Now, there are those rare times when you are unexpectedly (and I'm going to presume inadvertently) provided the opportunity to actually delight in witnessing someone shooting themselves in the foot, cutting off their own nose to spite their face, laying a trap for others & falling in themselves: