The first time I met Tom his head was on the table at the Christmas banquet held by the mental health support program where I worked. He was sitting next to his wife, who worked on the staff.

Tom’s alcoholism soon brought him into the program, fractured his marriage, and I became his first case manager. The alcoholism had roots in childhood abuse.  Years of drinking followed, with hospitalizations, chaos and plenty of charm and fury. Tom had a huge heart and capacity for engagement. He was a hard worker. Quick, smart and helpful, he was never mean or angry.  People were drawn to him for his sense of humor, warmth and playfulness.  The days he was able to take care of his little daughter were precious to him. His relationship with his wife remained loving, although she soon left the area with their daughter and became a social worker in another state.

And I too left the agency as did some of his original staff. After the requisite two years of no-contact, we all were able to re-connect with him from time to time. He was often a delightful companion.

After years of intermittent crisis and stability, Tom started Seroquel and immediately he was able to maintain his commitment to sobriety. His life became stable, predictable. He found steady work, and moved into a home on the property of one of his steady supporters.

Then, managed care came into the area. The county was forced to assess their clientele and dis-enroll those who seemed to be doing well. Tom’s support program workers were dismayed, and thought long and hard about Tom’s situation. In the end, though, the county cut him loose.

When I ran into him after years of not having seen him, he was still working and living in his home. However, he was very worried, in ways I couldn’t quite understand. He told me he was going to lose his medical benefits, that he couldn’t afford his medicine. He may have also mentioned that his relationship with his daughter and wife had apparently vanished. His thoughts were churning, his distress was evident and I didn’t know what to do about it. I didn’t fully grasp the significance of what I was hearing. I hadn’t known about the critical difference the Seroquel made for him.

Neither, apparently, did the nurse for whom he worked, nor the county worker whose property he was living on and who had seen him through thick and thin. When he started drinking again she told him to stop. He continued to show up for work but often didn’t answer his phone or return messages. There were no calls from his daughter or wife after he had missed her graduation. What they didn’t know, until it was past too late, is that he was supporting a family member with a drinking problem that day. It was a decision that dove-tailed with his dislike of travel and they thought he’d just blown off her special day.

It was the perfect storm. No meds, no calls from his family, no supports, no hope. The day he didn’t show up for work his co-workers went to his rural home and found him. He had shot himself in the head.

The signatures filled the book at the funeral home. The room was packed for hours. Tears streamed down the faces of his adult daughter and his wife. Slowly the pieces came together.

So much love; so much pain.

So, the question remains: what part of “doing well” means that critical supports can be removed?

We know that if a person who does well on a medication and stops taking it, our response is: “help me understand why, if you’re doing better on that medication, did you stop taking it?”  Tom wanted to be well. He didn’t stop taking his meds because he couldn’t handle health. He didn’t have that choice.

Is managed care worth the price of a life?

Kristy Jensch is a former case manager.

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