I talk about healthcare law a lot, but mostly in the context of how trans people are lawfully entitled to access to care.

There are many systemic problems in healthcare, but there's one I want to focus on for a moment of your time. 1/x

My experience as a mental health patient has been that there are two modes.

Therapy, where the ill person gets some unit of time (often 45 minutes) at some frequency (I hear every two weeks)

Hospitalization, inpatient or out, where the ill person has to focus their life on it

These two modes aren't enough and they're not doing what they're supposed to do. Mental health practice is obliged to serve people with mental illness, to help us work towards our own wellness.

This is radically opposed to most forms of clinical practice. 3/x

Many mental health providers simply refuse to take health insurance, denying care to the majority of people who can't afford mental health care bills without insurance kicking in (as they are legally obliged to do). This is one of the smaller hostilities towards us. 4/x

The larger hostility, that I believe drives a number of people away from mental health care, is that mental health practitioners are often not clear and concise about what is and is not privileged communication and at what point a person with mental illness loses agency. 5/x

There are whole classes of mental illnesses for which "there is a point at which you will lose agency" is a barrier to receiving care, and the basic legal facts -not your lawyer, not legal advice, just experience - are that it's usually really hard to hit "loss of agency." 6/x

That's important to know it drives people away from mental health treatment we need because we are scared that someone is going to take us away for being crazy.

In the U.S., it basically boils down to "are you an active threat to yourself or others." 7/x

I am licensed to practice in exactly one state, and this is a field that varies by state, but there is likely to be a nonprofit that breaks down any state's law on informed consent in mental health.

First, you have a right to know your rights. Simple due process. 8/x

Lawyers are required to disclose ways in which our privilege can be neutralized. For instance, lawyers have an ethical duty not to present perjury, but also usually have a duty to disclose that to clients

That's much less respect that people with mental illness often receive 9/x

There is a small set of things for which therapists are mandatory reporters. In many states its things like child abuse or elder abuse.

There is an even smaller set of things for which therapists are so much as *able* to get someone into a hospital. It's often really hard! 10/x

To qualify for hospitalization, a patient usually needs to be a genuine threat to themselves or others. Outpatient hospitalization has fuzzier lines, but still often centered on "is this person at risk of hurting themselves or others without intervention." 11/x

So, as a mentally ill person who doesn't want to have my agency taken away, here are some things I do:
* when seeing a new provider, start with a short discussion confirming what's reportable and what's subject to commitment, and clarifying that none of the other things are. 12/x

That establishes an open and honest rapport about the limits both practitioner and patient are operating under. I haven't had anyone waffle on these, but if I did, that person probably isn't the right clinical fit for me for *a number* of reasons. 13/x

[cw: suicide]

Another thing I do: discuss my suicidal ideation, when it appears, in context of my overall safety, to ground the conversation. The big three things in the context are plan, means, and intent. When I communicate that I have no intent, that answers "safety." 14/x