A few weeks ago I was sitting in the psychiatric outpatient clinic that has treated me for four years. The person who knew my case was gone. Nobody had told me. There were other doctors in the same corridor who could have taken over the file. I asked for two things: that someone continue the treatment, and a report on what had been done so far. The answer to the first: go to a doctor in private practice, get a referral, and come back. The answer to the second: write an email and something will be sent to me.
Before I ever reached that clinic, four doctors in private practice had seen me, one after another. Each said the same thing: this goes beyond what I can do here. Each sent me on. The fourth sent me to this clinic because the case was too complex for a practice. Now the clinic sends me back to a practice to fetch permission to return to the place the practices sent me to. Nothing about my condition changed in between. Only the person who knew it left.
In July I described how the answer to I am getting worse was a list of names. This is the piece before that: why the names on the list are not the problem.
What works
I want to be precise about what works here, because it does work. I am insured. The clinic is free. The medication is paid for. In eleven years I have never paid for a psychiatric appointment, and in most countries that alone would make me lucky. What does not exist is the one thing my condition needs most: the same person, over time.
The lottery
With autism and ADHD together, every doctor begins by not understanding the case. That is not an accusation, it is the nature of the case. It takes several appointments before anyone sees the pattern instead of the symptom of the day. So the value of a doctor is not in the first appointment. It is in the fifth.
That is why every appointment is a lottery. You might meet someone who takes the time, reads the file and tries a new combination. You might meet someone who does not want to listen, does not want to write a report, and closes the file with a referral. In eleven years I have seen more than a hundred doctors. A handful gave me time. There is no way to select them, and no way to keep them.
The pressure
This is where the system turns against the condition it treats. If I miss an appointment, I do not lose an appointment. I lose the doctor. Next time I sit in front of someone else who starts from zero, and I have to decide again whether to spend the first three appointments explaining or to give up. So every appointment carries the weight of all the ones after it. For someone whose difficulty is initiating and sustaining action, that pressure is not a side effect. It is the condition itself, amplified by the shape of its treatment.
The rule of least work
Every office and every clinic runs on the same quiet rule: take the case that has a known procedure, and turn away the one that does not. Not out of malice. A complex case means reading a thick file, making a decision nobody has made before, carrying a risk. If a case has a one percent chance of going wrong, the safe answer is no, or a referral, which is the same no with a different address. Nobody is ever punished for a referral. So the case with the greatest need gets the least work, from everyone, in turn.
The cost of that complexity does not disappear. It is transferred to the one person who cannot refer it onwards: the patient. And it accumulates. A diagnosis that arrives ten years late is not one lost decade. It is a degree, begun without knowing why the lectures were impossible, abandoned without a single adjustment because there was no name to adjust to, and read afterwards as a lack of will. It is job applications written while an untreated condition made the interview the hardest part. Every step was decided by someone doing the least work, and the sum of those small decisions is the loop on the front page.
The same shape, everywhere
This is not about psychiatry. It is about complexity. My left eye tells the same story in different words and in the same order: first the doctors in private practice gave up, then the hospitals operated, several times, insured and free, then the hospitals gave up too. Nothing more can be done. Every second opinion after that was private, and a private specialist costs money I do not have. So “nothing more can be done” became the final word, not because it was true, but because the next opinion had a price.
Everything complex works this way. A simple case fits in a form: one diagnosis, one doctor, one appointment, done. A complex case needs what no form can request: someone who follows it over time, who holds the earlier attempts in mind, who is still there next month. The public system offers appointments. Continuity is sold privately. Whoever has money buys a doctor who stays, a lawyer who stays, a second opinion when the first one gives up. For whoever does not, complexity is not a diagnosis. It is a verdict.
That is the pattern running through this whole site. The diagnosis came late, the treatment came late, every adjustment came late. Not because the care did not exist. Because the care consists of a series of strangers, and a complex case needs one person who stays.