The Shortage of Mental Health Care

here's what it looks like up close

You’ve probably heard that there is a shortage of access to psychiatric care in many parts of the country. Here’s what that shortage looked like for me during the summer and fall of 2023.

Prior to that summer, my best friend, Chris, was enticed by his children to take up disc golf, a favorite activity of mine. I was thrilled to spend time with him outdoors, sharing the joy (and sometimes heartbreak!) of what is, essentially, a plastic pie-pan, gliding 350 feet through the air, gracefully turning just so.

We played often. One hot Sunday afternoon we met up with a group of around eight other players. One by one, through some alchemical process, each one of them dissolved into the humid air, transfigured to a disembodied voice. After a few minutes, the only person left with a body was Chris, accompanied by this dissonance of serious speech, eight priests giving different homilies at the same time. Then the bugs appeared. They’re called ‘Palmetto bugs’ around here, but you probably know them as ‘roaches’. They churned on the ground. The crunching of leaves was revealed to be the crunching of bugs.

It can be a good idea to hide these experiences from other people. If you don’t, you end up in the hospital, which is worse than wading through wriggling bugs. But Chris recognized something wrong, and he offered that we could leave, his voice betraying his concern. I felt ashamed and guilty.

The bugs were either too busy or too polite to return that summer, but the voices became increasingly persistent, numerous, and challenging to sort out. (“Sorting out voices” is a topic for another time.) Then thoughts that are usually dormant began to crawl on my skull, feeling for a way in. “You aren’t human.” “You’re an alien.” “Imposter.” “You aren’t even real.” I resisted.

By late summer, the defenses were flagging. Drinking plenty of liquor helps, and is fun for a while, but it isn’t a sustainable strategy. Something else needed to be done, and the prospect of going back on medication gradually became less scary than the prospect of completely losing grip.

I wavered. It isn’t just that the medication is likely to be some scary mash-up of Clozapine, Haloperidol, and Lorazepam, plus the ‘adjuncts’—the stuff you take to try to mitigate the humiliating side effects of the other stuff that you take. (Yes, it feels a bit like swallowing the bird to catch the spider to catch the fly; please let’s not get to the horse!) The other obstacle is a robust pride in being able to live a good life without medication. It is very pleasing to have developed strategies that work. Hallucinations and intrusive thoughts have been around most of my life, and presumably will remain so; I prefer to think that I can handle it all myself, silently. That pride is a lot to swallow. It took time.

If you seek anti-psychotic medication, first find a psychiatrist. I had been on my own since my previous doctor retired. So let’s find a psychiatrist.

We can skip the six weeks or so that it took to get into a GP’s office. Once there, I spilled my story, which is never easy to do. Fortunate for me, he was sympathetic. It turned out that years ago he had done a residency in a psychiatric ward, so he wasn’t as scared as most doctors are of the s-word. He listened, although the classic ‘lens drop’ (glasses off to convey empathy) was a little much. Still, he is likable and sincere. He assured me that he knew a good psychiatrist. The gears began to turn.

But they didn’t turn far.

The general procedure around here is that the GP sends the referral to a medical social worker, who, after some cross-examination, connects patient with psychiatrist. The medical social worker was chipper, which was nice, although very reluctant to accept that I do not speak on the phone. Her resistance to email and my insistence on no phone conversations made for a somewhat dysfunctional relationship. Then she went on vacation (without me). In all, it ended up being a few weeks before the news arrived: Yes, the good psychiatrist was taking new patients, but not patients with your problems. Rest assured she would ask my GP for another referral. We would find a different, equally good, psychiatrist. (I was hoping for better, but at least they weren’t looking for worse.)

A few more weeks passed, and then fresh news: A (second) good psychiatrist is taking patients and his office will get in touch; but also you should call his office (ahem…) if you don’t hear anything within 7-10 days. The ambiguity of “7-10 days” was paralyzing. It seems that 7 days is plenty of time for them to get in touch. But then why are there the other three options—8, 9, or 10? And why not 11? What happens if you wait until 11?

I waited two weeks.

By then it was September, and classes at my university were running hot. At least in this matter, the cosmos was on my side—I had been scheduled to teach nothing but logic, which I can do on little sleep, with one hemisphere of my brain tied behind my back. So work was fine, maybe even beneficial.

Once I had convinced myself that yes, two weeks is an acceptable time to wait, a little research yielded the location of the (second) good psychiatrist, only a mile or two from campus. I walked over in hopes of nudging this process along. The building was creaky, with narrow hallways, a cheap 1970s hotel yanked up from somewhere in the middle of the country and dropped into the deep south. One hallway had a glass window, behind which sat, I hoped, the person who could get this business rolling. I explained the situation: I was supposed to have heard about an appointment, and was just, you know, if it’s OK, checking whether we could maybe, if it isn’t terribly inconvenient, go ahead and make an appointment?

Behind the window, the woman tapped on her computer. A bit of ‘hrm’ and ‘mhm’ later, she looked up. “I’m sorry,” she said, speaking as an elderly cat might speak, “we turned down that request.” Stunned, I asked, “Did I miss a message from you?” She shrugged. “We don’t send those notifications. Sorry.”

Her empty words created a void that caused the solar system to shrink to around six feet wide, leaving only the floor and a little space in front, surrounded by a shaking dark fog. Finding the outdoors, I stood at the curb; locomotion was no longer an option. “Are you OK?” I could hear a woman asking, and could just about make out her body. My scalp was agitated and bursting with replies but they weren’t making it to my lips until, finally, I managed to speak: “yes I’m fine thank you.”

My instinctual Midwestern politeness was, it seems, not persuasive. Normally I am very attuned to sirens, but somehow I missed the approach of an ambulance—it pulled up to the curb from nowhere. The EMTs appeared. Evidently, they were looking for me. I ran.

I was once a pretty fast fellow. I’ve raced many triathlons, and the memory of them is still in my legs, and lungs, and heart. On the strength of that memory, I ran hard and fast. A couple of miles. Even in my mid fifties, and no longer seriously exercising, losing the EMTs was not difficult. (In honesty, their chase was probably half-hearted.)

Running swept the fog away, and with some awareness regained, I continued to my GP’s office and explained the predicament. The woman who helped me was kind, and after 20 minutes of fiddling with a computer, and a few consultations with co-workers, she was confident that somebody would be in touch in 7-10 days, but, of course, with the usual caveat: “If not, please get in touch with them.”

Let us pause to mull over the fact that only building contractors surpass doctor’s offices in their need to issue this advice. (I don’t know about builders from experience—I have never trusted builders to fix my house so I always do it myself. But I’ve heard stories. And I watched A Year in Provence.) When they say “you’ll hear from us in 7-10 days but if not, please get in touch” it sounds like “please take responsibility for our delinquency.” (Memo to my students: “If I fail to come to class, please get in touch.”)

Two weeks passed. On the brink of giving up, it seemed increasingly plausible that the only way to get help was be to hospitalized. Jumping into the abyss was looking more and more tempting. How easy to let go, to become well and properly mad. Somebody—your wife if you are lucky, or the police if not—will drive you to the ER. You will tell the nurses of the daft ideas scrapping about your mind, and the fully unintelligible ideas cracking at your ears, and doing so will guarantee care, albeit at the dear price of gray linoleum and fruit cocktail. (On the plus side, they’ll probably take away your phone, which could be nice.)

I considered one more try. Full-on madness is always available as a backup plan, though a plan that charges one with guilt even in the pondering. One might accidentally fall into the abyss—that’s fine—but one isn’t supposed to jump. I lay in bed trying to work out what to do.

Lack of sleep almost put ‘the backup plan’ into motion without further debate. The voices had been multiplying all night and by morning were close to intolerable; the idea of shoving pencils into my ears seemed almost attractive. From the center of the whirlpool, though, one voice, a good voice, a calm voice, spoke the correct advice: “Hush. Drink some coffee. Go make the appointment.” I did, and in late November, well over four months after I had resolved to seek care, I went to that appointment.

The story of what happened next is for another time. Let’s play some disc golf.