The Curious Psychology of “Disability”

I’ll start this post with a brief clinical vignette:

I have been seeing Frank, a 44 year-old man, on a regular basis for about six months.  He first came to our community clinic with generalized, nonspecific complaints of “anxiety,” feeling “uncomfortable” in public, and getting “angry all the time,” especially toward people who disagreed with him.  His complaints never truly met official criteria for a DSM-IV disorder, but he was clearly dissatisfied with much in his life and he agreed to continue attending biweekly appointments.  Frank once requested Xanax, by name, but I did not prescribe any medication; I never felt it was appropriate for his symptoms, and besides, he responded well to a combined cognitive-interpersonal approach exploring his regret over past activities as a gang member (and related incarcerations), feelings of being a poor father to his four daughters, and efforts to improve his fragile self-esteem.  Even though Frank still has not met criteria for a specific disorder (he currently holds the imprecise and imperfect label of “anxiety NOS”), he has shown significant improvement and a desire to identify and reverse some of his self-defeating behaviors.

Some of the details (including his name) have been changed to preserve Frank’s privacy.  However, I think the general story still gets across:  a man with low self-worth, guilty feelings, and self-denigration from his overidentification with past misdeeds, came to me for help.  We’ve made progress, despite a lack of medications, and the lack of a clear DSM-IV (or, most likely, DSM-5) diagnosis.  Not dramatic, not earth-shattering, but a success nonetheless.  Right?

Not so fast.

Shortly after our appointment last week, I received a request for Frank’s records from the Social Security Administration, along with a letter from a local law firm he hired to help him obtain benefits.  He had apparently applied for SSI disability and the reviewers needed to see my notes.

I should not have been surprised by this request.  After all, our clinic receives several of these requests each day.  In most cases, I don’t do anything; our clinic staff prints out the records, sends them to SSA, and the evaluation process proceeds generally without any further input from us (for a detailed description of the disability evaluation process, see this article).  But for some reason, this particular request was uniquely heartbreaking.  It made me wonder about the impact of the “disability” label on a man like Frank.

Before I go further, let me emphasize that I’m looking at Frank’s case from the viewpoint of a psychiatrist, a doctor, a healer.  I’m aware that Frank’s family is under some significant financial strain—as are many of my patients in this clinic (a topic about which I’ve written before)—and some sort of welfare or financial support, such as SSI disability income, would make his life somewhat easier.  It might even alleviate some of his anxiety.

However, in six months I have already seen a gradual improvement in Frank’s symptoms, an increase in his motivation to recover, and greater compassion for himself and others.  I do not see him as “disabled”; instead, I believe that with a little more effort, he may be able to handle his own affairs with competence, obtain some form of gainful employment, and raise his daughters as a capable father.  He, too, recognizes this and has expressed gratitude for the progress we have made.

There is no way, at this time, for me to know Frank’s motives for applying for disability.  Perhaps he simply saw it as a way to earn some supplementary income.  Perhaps he believes he truly is disabled (although I don’t think he would say this—and if he did, I wish he’d share it with me!).  I also have no evidence to suggest that Frank is trying to “game the system.”  He may be following the suggestions of a family member, a friend, or even another healthcare provider.  All of the above are worthwhile topics to discuss at our next appointment.

But once those records are sent, the evaluation process is out of my hands.  And even if Frank’s request is denied, I wonder about the psychological effect of the “disability” label on Frank’s desire to maintain the gains he has made.  Labels can mean a lot.  Psychiatric diagnoses, for instance, often needlessly and unfairly label people and lead to unnecessary treatment (and it doesn’t look like DSM-5 will offer much improvement).  Likewise, labels like “chronic,” “incurable,” and “disabled” can also have a detrimental impact, a sentiment expressed emphatically in the literature on “recovery” from mental illness.  The recovery movement, in fact, preaches that mental health services should promote self-direction, empowerment, and patient choice.  If, instead, we convey pessimism, hopelessness, and the stigma of “disability,” we may undermine those goals.

As a healer, I believe that my greatest responsibility and most difficult (although most rewarding) task is to instill hope and optimism in my patients.  Even though not all of them will be entirely “symptom-free” and able to function competently in every situation life hands them, and some may require life-long medication and/or psychosocial support (and, perhaps, disability income), I categorically refuse to believe that most are “disabled” in the sense that they will never be able to live productive, satisfying lives.

I would bet that most doctors and most patients agree with me.  With the proper supports and interventions, all patients (or “users” or “consumers,” if you prefer those terms) can have the opportunity to succeed, and potentially extricate themselves from invisible chains of mental illness.  In Frank’s case, he is was almost there.

But the fact that we as a society provide an institution called “disability,” which provides benefits to people with a psychiatric diagnosis, requiring that they see a psychiatrist, and often requiring that they take medication, sends a very powerful—and potentially unhealthy—psychological message to those who can overcome their disability.  To Frank, it directly contradicts the messages of hope and encouragement I try to offer at each visit.  It makes him dependent upon me, rather than upon himself and his own resources and abilities.  In other words, to a man like Frank, disability is anti-recovery.

I don’t have an easy answer to this problem.  For starters, changing the name of “disability” to something like “temporary psychological material support”—a substitute label, nothing more—might be helpful.  Also, rewarding recipients (e.g., not repealing their benefits) for meeting predetermined milestones of recovery (part-time work, independent housing, etc) may also help.  But the more I think about the life-affirming and empowering potential of recovery, and about how we allocate our scarce resources, the more I believe that the recovery-based—as opposed to disability-based—practice of psychiatry has much more to offer the future of our patients, our profession, and our nation, than the current status quo.  For the sake of Frank’s recovery, and the recovery of countless other men and women like him, maybe it’s time to make that happen.

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48 Responses to The Curious Psychology of “Disability”

  1. Duane Sherry says:

    Dr. Balt,

    I’m amazed at how many of your colleagues continue to insist that the work of Robert Whitaker is not factual…

    They continue to say that the pharmacological approach and the rise in disability numbers is a casual relationship.

    Really?
    Are you kidding me?

    Have psychiatrists become so high and mighty that they cannot recognize a zombie when they create one?!

    Want to see a drop in disability roles?
    Stop prescribing antipsychotic drugs for the long-term.

    People cannot work when they are zombies.
    Hell, they can’t even get out of bed; they can’t hold their heads up in a chair!

    A call to your profession (in non-medical terms):
    “Stop sucking the dopamine out of people’s brains, and turning them into zombies!”

    Duane

    • stevebMD says:

      Duane,

      Not quite sure what point you’re trying to make here, but just for the record, Frank (the patient I described in this post) is not on medication.

      • AA says:

        Steve,

        I have to agree with Duane.

        I am also curious as this is the 2nd blog entry you have written on this topic recently. It just seems you are ignoring the other side of the issue which in my opinion is a whole lot worse.

        And Mara is right, even if these folks want to get off of disability, getting services is an exercise in futility. I definitely agree that most state voc rehab departments are a joke. and not helpful at all. By the way Mara, they don’t discriminate as they provide equal opportunity bad service at least in my area.

  2. Duane Sherry says:

    The point had nothing to do with your story… “Frank”.
    I was speaking to the larger issue – Disability.

    Psychiatry is causing disability, by prescribing drugs for the long-term, by burying their heads in the sand when it comes to the injury, especially the injury caused by antipsychotic drugs…

    The drugs are the root cause of this disability (along with the labels, and the trauma cased by “hospitalizations”, etc)

    Frank’s story had some good points, but the larger issue needs to be addressed. And it needs to be addressed rather quickly, considering the un-sustainability of the mental health system (SSI/Medicaid; SSDI/Medicare).

    The disability rates are increasing BECAUSE of psychiatry.
    And it is NOT a casual relationship.

    Duane

  3. catsrgreat says:

    Most people I know (including me) who get psychiatric disability are basket cases compared to Frank. I know them thru educational groups put on by our county’s social services provider (for severe and persistent mental illness) and thru a local socializing club for people with mental health problems. ??? Is it the people who are sicker who tend to take mental health classes, have a social worker and/or go to drop in centers? I am really puzzled!

    There are some who could handle part time work, and many of them do work part time off and on, it seems. I don’t know how they manage the SSI or SSDI paperwork when they fall into severe depression again. The social worker can fill out the forms for them, but the mental health client still has to consistently keep track of the pay stubs.

    • stevebMD says:

      cats,

      You will note that I’m not arguing against the value of disability for people with severe and persistent mental illness. In such cases, it can be a godsend. But the number of patients for whom some degree of recovery is not only possible, but readily attainable, but who nonetheless seek “disability,” is staggering. Indeed, some of these applications are denied (the pleas of their lawyers notwithstanding), but the psychological impact of applying for “disability” seems, to me, to fly directly in the face of the concept of “recovery,” something I believe all patients should strive for.

    • doctorz says:

      catsrgreat, I have patients who aren’t capable of writing what you have, and are working. Not saying you are lazy nor am I minimizing your “disability”, but the system may have robbed you of an opportunity of finding some type of employment that could have been gratifying to you. I consult part-time at a residential treatment facility for people with severe developmental disabilities. Many of these individuals are nonverbal and some are not toilet trained, but they are all employed! As a general rule, the mental health system in this country corrupts the mentality of its service population to become helpless, hopeless and hapless, and in some cases, reinforces preexisting feelings of victimization and entitlement. By happenstance, I reluctantly agreed (because of my lack of experience with the developmentally disabled) to work with another group of arguably more disabled people to see this phenomenon for myself. Furthermore, I find it intriguing that catch terms and phrases such as “recovery” and “evidence based practices”, which are insincerely recited ad nauseum in the mental health system, appear nonexistent in this work setting. How refreshing!

      • mara says:

        To be fair, it’s a little bit different when you are very obviously disabled. I like how comedian Carlos Mencia put it a long time ago. He brought up that we are nicer to retarded people than we are to stupid people. It’s okay to mock a stupid person, but its wrong to mock a retarded person. I would think someone who was severely developmentally disabled would get more understanding and accommodations on a job than someone who appears high functioning.

        Just look how we treat Dyslexic kids. Aren’t dyslexic people about 5 % of the population? I read they make up around 20% of the national prison population and the same percentage of people on welfare. I didn’t know that, but that makes sense to me that 20% of people on welfare would have trouble reading. Dyslexic people are generally intelligent people, so it probably does look like they are just lazy and have poor work ethic when they have trouble on a job that requires reading or even punching numbers into a cash register.

        If you look high functioning, your employer will not be very sympathetic if you have a hangup.

      • leslie says:

        I don’t know, Dr. Z, I was entrenched in the mental health system as a patient for about a decade and I didn’t hear the words “recovery” or “evidence based.” I heard the words “chronic” and “severely mentally ill.”

        They didn’t believe in recovery. That was the whole problem. Mental patients were seen as the chronically ill, needing meds for life. Getting well wasn’t part of their world view.

        I agree with this statement, “As a general rule, the mental health system in this country corrupts the mentality of its service population to become helpless, hopeless and hapless, and in some cases, reinforces preexisting feelings of victimization and entitlement.”

        I think being repeatedly told I had a chemical imbalance and I was ill, created helplessness. When the psychiatrist kept on and on about how I needed to take my meds and how ill I was, I turned to him once and said, “How am I supposed to know what’s the result of a chemical imbalance, what’s the result of meds, and what part is me? How am I supposed to know which is which?” It’s really no wonder patients are so confused.

      • catsrgreat says:

        You have no idea what my story is, and if you knew, you wouldn’t have used me as an example of failures of the system.

  4. mara says:

    I think you may be reading too much into this. As someone who receives SSI for mental health issues, I really don’t let the disability label define me. I still try hard to find ways to support myself. I do have hangups, but really, SSI is just a way to supplement your income. That is the whole incentive for being labeled. He may not even really consider himself permanently disabled. Or even if he does, he may still think it is something he can work around

    You know what you should be more upset about is Ticket to Work and Dept. of Rehabilitation. SSI is not a sham. It’s a good safety net for people with disabling conditions so they can support themselves and keep families together. I tried to get help from Ticket to Work. Ugh! I kept trying to get into a free CNA training program for people on SSI. They took my Social Security number, and then did nothing else. Every time I called it just went to the answering machine. If you are on SSI you get a giant list, pages long, of totally NOT legit vocational rehabilitation programs. That whole program is a failure. I explored it, but I finally just got some family help and signed up for some medical transcription classes at a community college.

    And then there is DOR…The vocational rehab. counselor wanted my psych records before she would help me. I don’t mean she wanted a diagnosis or proof I receive SSI (both of which I could give). I could not understand why my medical records would be necessary. This is especially because I highly doubt she is trained to understand it. Does she ask her deaf clients for their medical records? Her job is to accommodate my disability and find me suitable employment. She does not need my psychiatric medical records for that. I can get accommodations at the community college by providing proof of my diagnosis, and they do not need medical records for that.

    I’ve heard story after story of people with mental disorders who go to DOR and it’s a nightmare. One woman told them very clearly she could only deal with people some of the time, but she could not do it all of the time or she would get overwhelmed. They put her to work in a daycare :-/ She just got fired over and over again because of the jobs DOR put her in before she finally paid out of pocket for a private job coach who specializes in people with her disorder. He found her a job. I have no clue how she found a job coach who actually managed to specialize in her disorder, but it worked out well for her.

    I really don’t think mentally ill people are staying on SSI for so long because of low self esteem and thinking they are too disabled to work. I think Ticket to Work is a failure and DOR discriminates against mentally ill clients. I don’t have any proof, but I don’t think my medical records would have been necessary if I had been in a wheelchair, or deaf, or blind.

    • Duane Sherry says:

      Mara,

      Take Charge is an Employment Network (EN), approved by SSA/Ticket to Work that allows a person the opportunity to keep 75% of their ticket money –

      http://www.aaatakecharge.com/

      Dr. Balt,

      Having served as a vocational expert witness with SSA in over 200 cases (SSA/Office of Hearing and Appeals, administrative law), I can appreciate the fact that some people’s symptoms are at a level where they simply cannot work (whether physical or emotional, etc).

      SSA asks whether a significant number of jobs exist in the enonomy that a person can perform, looking at age, education, skill level, transferability, etc…

      I have tesifified more than once that ta person could not… My rant is not toward any person who is suffering… but toward a profession that seems to add insult to injury.

      Re: The antipsychiatry rant… Psychiatry is what it is, unfortunately. Would you really want to live in a country where at least of few of us weren’t holding your profession’s feet to the fire?

      Duane

      • stevebMD says:

        Duane,

        Thank you for your comment. It sounds like you have more experience with disability evaluations than I do. From where I sit, I see patients who tell me all of a sudden, “I got on disability!” without my knowledge, or who come to me on “disability” for reasons that neither they (nor their family members) can explain. I kid you not.

        Robert Liberman’s book “Recovery From Disability” draws a distinction among “pathology,” “impairment,” “disability,” and “handicap.” He describes “disability” as the unfortunate effect of impairment (symptomatic, cognitive, etc) on activities of daily living, while a “handicap” arises when a community or society does not provide adequate accommodations to people with such disabilities. Other writers, however, include the patient-society interface in the definition of “disability,” namely that a disability can result when a person simply has no access to services (or jobs, etc) that accommodate his or her (perceived) impairment(s).

        The former definition comprises what we try to treat in medicine (and can successfully do so, particularly with the tools of the recovery model). The latter definition is a more liberal one (in the apolitical sense). Most of my patients fit that definition; however, I maintain that simply “succumbing” to an unfair society does not a “disability” make. Should those patients/users/consumers receive financial support? Perhaps. (That’s not a decision for a psychiatrist or, IMO, for any medical professional.) But I prefer not to call it a “disability” because of the psychological impact such a label may carry– plus the other reasons I disclosed above.

        BTW, why you insist on making this discussion pro- vs anti-psychiatry continues to escape me, Duane.

      • Duane Sherry says:

        Dr. Balt,

        Re: Psychiatry versus Anti-psychiatry

        If three things took place, I think you would see the tone change from many of us “anti-psychiatry” types:

        1) Informed consent – all the facts presented to patients…
        ALL of the facts – from the diagnoses (legal implications), to the drugs (long-term side-effects), etc
        .
        2) An end to the use of force in the field of psychiatry…
        There is simply NOT enough science to force anyone to undergo “treatment.” Period!

        3) Support in helping people learn how to come OFF psychiatric drugs slowly and safely (especially children, elderly and war-traumatized veterans; along with anyone who was placed on these drugs without informed consent or by force).

        There are dozens of other areas that need to be addressed, but we need to start with these three areas…

        Once we can all get on the same page, and address these concerns, you’ll see and end to the rants by “anti-psychiatry” types like yours truly, and there will be some much-needed dialogue… some productive steps taken to improve the system.

        But none of this will take place if psychiatry is not willing to address these major concerns.

        Duane

      • mara says:

        Thank you Duane! That actually sounds like a good program. Gonna head to the library and print out an application. It’s hard to find stuff that is actually helpful. Cross your fingers.

    • Duane Sherry says:

      Mara,

      Take Charge is legitimate, and approved with SSA/Ticket to Work.

      My thought was that if your state VR agency and/or private employment networks have not been giving you assistance, and you’re willing/able to find your own way off disability and back to work, you can keep 75% of the ticket money.

      This is money that SSA would normally pay a private EN or kick back to the state DOR. And for many people, it would be more helpful to go back to work, and have this money themselves (after returning to work, and getting off disability income).

      My best,

      Duane

  5. catsrgreat says:

    I think the loss of my career, and subsequent failures at part time and volunteer jobs, moving on even easier volunteer jobs and failing at those, too, hurt me a LOT more than the label from SSA that I am supposedly disabled. I picked myself up out of the gutter so many times and tried over and over again, for years, and eventually I was sick more of the time than I was well, so there wasn’t much choice anymore what to do. I am very ashamed of myself for not being able to work, or consistently volunteer. I don’t think it’s the disability income that’s the issue. It’s the inability to work. I think seeing labels for people like me in state laws: “mental defectives,” that hurts me way more. And it hurts me very much that I have to hide my medical problems from others because they might be afraid of me or despise me because of a label. I skulk around in secret, when I have done nothing wrong. The disability income itself, I am so grateful that society chooses to provide for disabled folks.

    and to Mara, the SSA requires medical records for all disabilities. My first husband had severe physical disabilities from birth defects, and he had to send in medical records same as me. He worked part time, and it was horrible filling out the forms, because he made a different amount of money each month and we were overwhelmed all the time with his illnesses and my depression. Then when he would get very sick and not be able to work for a long time, the SSA would take a long time to adjust his income, so we would struggle. Then they lost his chart, too, and more delays. Hopefully computers have fixed that problem. I haven’t known anyone who did the Ticket to Work program – most people I know had some good job skills, and tried to keep them up, but they are sick too much of the time to make it to a job site consistently. So they kind of fall into little jobs from time to time. That’s how my former spouse did it. He had a lot of grit.

  6. catsrgreat says:

    Oh, and Mara, sorry, I re-read your message and I guess I got tired and misunderstood what you wrote and I mixed up the SSA with DOR regarding the medical records. Sorry again.

  7. leslie says:

    I agree with a lot of this post, but I do think Frank is the exception rather than the rule. Most patients I knew seeing a psychiatrist were not only medicated, they were heavily medicated. It’s hard to work or even want to work when heavily medicated.

    I spent about a decade with a diagnosis of a severe, chronic mental illness. My psychiatrist constantly hammered into my head that I had a severe mental illness requiring meds for the rest of my life and being a good, compliant psych patient means that I accepted it. If that won’t suck the hope right out of you, I don’t know what will. I know from experience that it’s pretty impossible to work when drooling and zonked out of your mind on drug cocktails, believing in the diagnosis and prognosis. I wasted about 10 years of my life under that treatment paradigm.

    So, I think Duane is right in that psychiatric treatment can create and encourage disability. But, I also think that if patients find the kind of treatment that is more recovery focused rather than disability focused, that can help turn things around. Recovery for me meant that I had to be a bad psychiatric patient and refuse to accept the original diagnosis and prognosis. I needed someone who believed I could be well before I could believe it myself.

    • stevebMD says:

      leslie:

      Frank may be “the exception rather than the rule,” but I can say that cases like Frank’s are all too common. I won’t go so far (as some of my colleagues have done) to accuse people like Frank of abusing the system or deliberately faking symptoms to obtain services. As I wrote, I don’t know Frank’s motives.

      Nevertheless, I wrote this post because I believe “disability” has the potential, in many patients, to be anti-therapeutic. First of all, the process of applying for and obtaining disability benefits is something that happens outside of the awareness of the typical psychiatrist and therefore outside of the therapeutic relationship (people apply on their own, they see “evaluators” other than their own physicians, and law firms, not doctors, often act as aggressive advocates– and not for purely altrui$tic rea$ons, mind you). Second, simply the label of “disability” (just like the label of “schizophrenia” or “mental illness”) can have great, often subconscious, negative psychological implications to the patient. And finally, trying to employ the concepts and strategies of “recovery,” rehabilitation, and patient-centered care, is often futile, as patients are understandably reluctant to give up the benefits of disability (mainly, a steady income and health insurance), making the “end point” of treatment one big question mark.

      I agree with you and with Duane that some people become more incapacitated when taking psychiatric medications. I also agree with cats, mara, and AA that many people truly benefit from (and need) disability (when they can access necessary services!) and don’t let that label “define” them. However, in this post, I’m talking about a different group of patients: namely, those who unfortunately stand to lose the most by this process that, IMHO, is in desperate need of reform.

  8. catsrgreat says:

    When the question comes up, I always tell people that applying for SSDI should be their LAST option, because once you are on there, you have a huge gap in your employment record and you are always going to be worried about leaving secure medical insurance for the intermittent health insurance in the job market. Therefore, you will probably be too afraid to get off of disability, and be trapped in poverty the rest of your life.

    My former spouse (whom I mentioned in a previous post, has severe physical disabilties due to birth defects) had to be so careful not to lose his medical insurance. If he lost his insurance due to working too much, and had to get care in the ER only, he would not have lived very long (literally). He needs to be followed closely by a physician. Fortunately, he worked intermittently long enough that eventually he qualified for the Medicare program, which has more lenient rules than the MediCal (CA medicaid) program did at the time. I mention this whole thing because if he were somewhat healthier, he still wouldn’t dare work too much and get off disability and lose medicare or MediCal.

  9. Carol Levy says:

    To me part of the problem is that you can get an attorney for the frist time application. 65% of all first time applications are denied. Lawyers, as well as others have told me this is to help weed out the ‘scammers’. On the second round a lot drop out not wanting to take the time, effort, hassle. (For disclaimer, I went on disability in 1980 for facial pain – trigeminal neuralgia. I lost first time, no lawyer, without attorney was granted SSD on appeal.)
    You can work while on disability (I know nothing about SSI). Last I checked, a while back, you could make 900$ a month and remain on disability. If you could work, you had 3 months to prove you could do sustainable work, then stayed on ssd for a year so you had income to tide you over. This is a nice carrot.
    Ticket to work tried to work with me but was unable to find anything -Anecdotal here on both sides. Probably comes down somewhere in the middle of helpful vs. not.
    You do need the state’s doctors to evaluate and concur that you are disabled (to my knowledge that has not changed, so it is not a simple issue of saying “I am disabled.”)
    I think Frank has a responsibility here. Why has he chosen to try and go this route (it can take 1, 2 years before getting disability so this is not a quick ‘fix’ to his financial issues.)?
    Calling yourself ‘disabled’ is a choice. Just because the state uses that word does not mean that it is a label one needs to use, after all it is a work ability label, not a life label. (It is only recent, after 30+ years, that I have stopped writing on forms disabled – at present.).
    I fought the label in temrs of ‘occupation. Talking about it recently others have said “But wait, you are an author, a writer, a hypnotherapist, a singer, a baker. You are many, many things. It is a choice to go with “Disabled” as your identification.

  10. Keris says:

    Lots of valuable info here and thoughts. One of my suggestions might be to ask the people you serve (patients/clients) what they think about the term “disability” and/or if they equate being on SSI with being labeled “disabled”. I might also ask if one considers the disability to be time-bound (short-term versus permantantly disabled).
    I understand your points (and agree whole-heatedly related to others’ comments on meds, though that’s not your focus here), but worry that there is an imposition on your part about how one with a mental health diagnosis interprets the label “disabled”.
    For example, I was on SSDI twice in my life and I have a mental health diagnosis at the time I was “disabled” and wanted to get the heck off of SSDI! I do not consider myself “disabled” now though I still have the diagnosis, am not symptom free, still see a psychiatrist, take meds as needed, engage in other self-supports and work full time. Someone once described me in a letter to speak at an event as “disabled”, I was furious as currently I’m hardly disabled!
    I think you will find many in the mental health recovery movement (meaning those with diagnosis supportive of, believing in and living out recovery) are actually in the public mental health system, receiving benefits and engaging in other self-supported “treatments” such as peer support. Further, everyone with mental illness regardless of diagnosis or weather defines as “chronic and persistent” can recover according the true understanding of recovery as it pertains to mental illness. To say any less is to pick and choose who can and cannot “recover” as well as to deny “hope” to people who actually may need it the most.
    Lastly, I’d encourage you (and your readers if you haven’t) to read the New York Times 5-part series written by Benedict Carey “Lives Restored”. I was also featured in the profile series (part 3)… (http://www.nytimes.com/2011/10/23/health/23lives.html?_r=3&scp=1&sq=Keris%20myrick&st=cse)
    These profiles are a great example of the possibilities and recovery journies of people
    with as some might say “chronic and
    persistent mental illness”.
    Thanks so much for bringing up this topic of “disability” given the over-representation of people with mental health diagnosis on SSI and often stuck with in this safety-net system.

  11. Disability is indeed a label and to get help people often have to get an official diagnosis of disability. The process does internally stigmatize the person in cases. It becomes a learned helplessness reinforced by the system that says anything but hale and hearty is defective. Notwithstanding that, financial assistance is not a luxury while someone attempts to come back from their inability to cope.

  12. Abie says:

    I’ll preface this by saying that I know that SSI and short term disability insurance are very different, and of course every person is an individual. That said, I can only speak for myself.and the experiences I had – even though they are in some respect the opposite of Frank, though perhaps with your same conclusion. As a well educated (graduate and post graduate Ivy League degrees) professional, I have severe MDD. Some ten years ago I wound up hospitalized, unemployed and with zero options aside from short term disability insurance. I am quite aware that I am highly competent blah blah blah but submitting that form was one of the hardest things I have ever done. To this day, looking back on it all, remembering that I was on disability is one of the most traumatic pieces of it all. Labeling, and self-labeling is horrible. I don’t know that it’s a self-fulfilling prophecy, but it is a self-damaging prophecy. And this was short term disability. For SSI itself? I don’t know. That said, it is impossible to get better if you don’t have a home to live in because you can’t pay your mortgage because you can’t work because you’re so severely depressed you can’t make it out of bed. But what’s the other option other then SSI? And isn’t SSI to some degree just reinforcing that you don’t need to work your ass off to get better enough to be a person? So, I don’t know where the line is. I really don’t.

  13. leslie says:

    Dr. SteveB, I actually agree with about 99% of what you wrote in this post. When I was talking about Frank being an exception, I meant teh exception being that he was seeing a psychiatrist yet not being medicated by the psychiatrist. I don’t doubt you guys see quite a few people who are not disabled yet want to receive disability benefits.

    I know not everyone is probably as negatively affected by their diagnosis as I was, but for me the constant reminder by the psychiatrist of my “severe, recurrent major depression” reinforced feelings of hopelessness and helpessness. Because if it’s recurrent, that told me it would be back with a vengeance and this was going to be my life. I needed a much different message.

    Embracing the diagnosis, I think, can actually be detrimental. I saw it when I was inpatient. Many of the good, compliant psych patients were comfortable in their sick role, and I don’t think that appeared to be helping them much. One woman told me she came into the psych ward periodically “to rest.” Shouldn’t someone recommend a nice spa?

    When I look back on my time as a patient diagnosed with a severe and chronic mental illness, I actually believe that my fighting to get out of the psych ward was a sign of sanity that instead of being viewed as a sign of illness, should have been embraced and supported. Fighting against the diagnosis and dismal prognosis was life saving for me. I would celebrate those who fight against the sick role. Those who want out would get a gold star.

    Disability for me would have been a disaster and yet another reinforcement of my perceived helplessness. Lucky for me I was too ill to get it together to apply. No way I could have coordinated all of that back then.

    I do think for a diagnosis like major depression, there should be no such thing as long term disability benefits. Collecting a check while being able to remain isolated, shut up in my apartment would have only reinforced depression. I would likely still be lying on my sofa in the dark.

    Hopefully, there are more psychiatrists out there like you who recognize that enabling depression doesn’t help patients.

  14. leslie says:

    I blabbered on in my response above about depression and then realized Frank was diagnosed with anxiety NOS, not depression. I guess I’m so used to the two being linked together, that I read anxiety and thought depression. Anyway, maybe none of what I wrote applies to Frank or maybe it does.

    Carol asks the most important question. Why has Frank chosen to try and go this route (it can take 1, 2 years before getting disability so this is not a quick ‘fix’ to his financial issues.)?

    Maybe I missed it in the original post, but did Frank have a previous psych hx when he presented to the clinic? Was he treated in the past for a “severe” and “recurrent” illness? If so, then maybe he believes he is disabled because that is what he was told in the past.

    Or maybe he is just trying to supplement his income.

    I’m curious to know Frank’s reasoning. A follow up post would be good.

  15. Rob Lindeman says:

    Steve,

    Rather than allow your staff to handle these requests, review them yourself. If, in your professional judgment, the individual is not disabled, don’t return the request. The application may be granted, but without your endorsement.

    I receive one of these a month, on behalf of a child. 95% the child is not disabled in any meaningful sense. 4% of these the child is meaningfully disabled but the parent is able to work and earn as though the child were not disabled. These 99% end up in the circular file.

    • mara says:

      Rob,

      You say that in 4 percent of the cases the child is meaningfully disabled, but the parent is still working and earning enough to support the child.

      How do you feel about millionaires who collect unemployment when they don’t really need it? I read an article about that a long time ago (super wealthy people who don’t have to work, but they still collect unemployment.) When asked if they feel guilty about collecting unemployment, they said no. And I thought their reasoning was interesting. They worked, paid into the system, and they are entitled to that money. It doesn’t matter that they technically don’t have to work a day in their lives. They are unemployed, and the unemployed have every right to collect money for a certain period of time.

      So what about a kid who is disabled, the parent is a tax payer, and the parent has every right to collect money for the kid’s disability? The parent can afford to support their kid with no government support…but they did pay into the system. So are they not entitled to the extra cash to pay for their kid’s special needs?

      I’m just saying, you don’t think parents should collect disability for a kid when it doesn’t affect their ability to earn and support the kid. But do you feel the same way about millionaires who are unaffected by the loss of their job? They won’t lose their home, and working is more like an option than a necessity.

      • Rob Lindeman says:

        It sounds like a rhetorical question. Should rich people obtain benefits they don’t need? No. Is it supposed to be a tough question?

      • Mara says:

        Maybe it is a tough question Rob. Unemployment is a a form of insurance that they paid for. So is disability. If they paid for that insurance, shouldn’t they get the benefits?

  16. Rob Lindeman says:

    I pay for my own disability insurance. I don’t expect anybody else to pay if, G-d forbid, I become disabled. As for unemployment insurance, NO ONE pays for it: it’s deducted from your pay check (or assessed as a tax?)

    • mara says:

      See! It came out of their paycheck. They technically “paid” for it it.

      I don’t know that I would collect unemployment if I were a millionaire…unless I wanted to donate my portion to poor unemployed people. But I got their argument that they worked, unemployment is like insurance that they paid for, and so they feel entitled to it.

      • Rob Lindeman says:

        The individual is not “paying into the system”, technically or otherwise. “Unemployment” is a tax assessed on his!her employer. The tax raises the cost of doing business, nothing more. The individual never sees the money. It is never his to pay into the system.

    • Rob,

      A little empathy would go a long way here, considering most people who find themselves disabled from a “mental illness” got there by being “compliant” with “treatment!”

      And, good, bad, or otherise, we have a system in place… taxes taken out for Social Security, both retirement and disability.

      As an conservative, I would remind you that Ronald Reagan worked hard to keep the Social Security system solvent.

      IF we are going to have such a system, it should work for those who pay into it. Money is take out of people’s paychecks (good, bad, or otherwise), to be there for them when they are older, or if they become disabled.

      Duane

      • Rob Lindeman says:

        Duane,

        Sorry, you got my politics wrong. I’m a Libertarian, not a Conservative, so appeals to the memory of Ronald Reagan don’t work for me. I also reject the notion that one can only feel empathy if one also assents to the proposition that the State should pay you if you can’t work. That’s nonsense.

        In any case, quite aside from the cases of those with financial liabilities who cannot work because they are physically unable to, we are discussing the cases of those who CAN work, but who petition the State for money on the basis of their own perception that they could make more money, but for their disability. Hence the cases cited above of WORKING individuals collecting disability payments. This is a game the State ought not to play.

      • Duane Sherry says:

        I can appreciate your libertarian sentiments, but would only add that people who have been traumatized by hospitalzations, long-term use of antipsychotics, and other mental health “treatments” need the opportunity to heal. They often cannot work, until they slowly taper off the drugs, and begin to heal, to overcome psychiatry.

        Duane

  17. lizzy says:

    i’m on “disability.”

    i hate it. hate it. hate it. for a couple of months, i was in the hospital/totally unable to work. by the time i got my first check this month, i felt much better (there is no payment for the first five months of disability). but i had waited so long, it seems foolish to start working NOW. what happens if in a year, i feel horrifically depressed again? then, my family has to go through this horrible can’t pay the bills/afford food process all over again.

    if i work now, but become crazy depressed and suicidal next year, our family could totally sink by the time i could get benefits again.

    and since i stopped working due to my depression/long hospitalization, i lost my insurance. that means that i no longer have a psychiatrist or counselor anyway, because i can’t afford one. so when it comes time to re-do the paperwork in two years, when i would qualify for medicare, there will be no one to fill it out, and i’ll probably be declared healthy. that’s sort of a good thing.

    i’m looking forward to going back to school and eventually back to work anyway.

    i think the whole “disability” system is TERRIBLE. if someone had said, you are REALLY having a tough time. you have been committed to a psych hospital by the COURTS. we’re going to give you disability payments for six months, but after that time, you have to get a job, that would have been SO MUCH MORE HELPFUL!!!!!

  18. lizzy says:

    also– i applied for disability and i did not use a lawyer; my case was approved without any hassle. i began the application process this summer, and just received my first check (mid december). granted, when i applied, i was (court-ordered) in-patient in the psych hospital after back-to-back suicide attempts. i was pretty screwed up. but now, six months later, i am in a TOTALLY different place- potentially able to work, but scared to fail at work and fail my family. not to mention that my family and friends frequently tell me– sure, you seem okay NOW, but what happens the next time you get depressed? and what if work stresses you out so much you become suicidal again?

    regardless, thank god for dialectical behavioral therapy. my skills instructor did tell me that he doesn’t see any reason why i can’t start school or work whenever my “wise mind” leads me to do so. my psychiatrist from the hospital asked me if i had ever thought about being a dbt instructor. their faith in me means SO MUCH and does a lot to take away the sting of the disability label.

    so, doc– for some people, it means a lot to hear a professional say– “you are capable of living a healthy, happy life.” keep saying that, and hopefully, more people will hear you!

    • leslie says:

      Lizzy writes, “so, doc– for some people, it means a lot to hear a professional say– “you are capable of living a healthy, happy life.” keep saying that, and hopefully, more people will hear you!”

      I second that.

  19. catsrgreat says:

    Lizzy, while on SSI or SSDI, you can go back to work part time. There is something called a trial work period in SSDI and I dunno if it’s called the same thing in SSI. And on SSDI, you can work full time for a few months as part of your trial work period, and will get benefits right back again if it doesn’t work out. You don’t have to go to vocational rehab – I’ve never known anyone who did. My ex worked part time most of his adult life, in spite of horrible physical disabilities, and he did not lose his benefits. I haven’t been able to work even part time for a long time, so I’m not up on the latest stuff. When I worked part time as a sales clerk years ago, though, the SSA did not discourage me in ANY way.

    When I was in California, they had a short term disability insurance system and people get short term disability insurance through work a lot of times, but for young people, or people who don’t have a professional job etc, there’s not much safety net. And private disability insurance doesn’t always want to pay up, either, no different than if you get injured in a car accident and they often low ball everything.

  20. stephany says:

    Psychiatric medications given over a decade of time to a growing child’s brain–rendered my daughter on SSI and Medicaid by age 18, stuck in adult psych mental health care loop, and the discharge care was always only a case manager who didn’t do anything except add another cook in the kitchen of system dysfunction. The psych med damage has resulted in this now adult child never being able to go to work like the rest of the world, or her high school classmates.

    Just an added perspective, as there are SO many kids now being medicated, it is not surprising that the increase of SSI disability rates have increased as well, and it will keep on going until we as a society get a grip on over medicating kids and teens.

    Most of the time, SSI requires extensive medical files and hospital files, names of doctors, not necessarily direct contact with a doctor is needed (per Steve saying he did not know some patients got disability until they told him).

    Sadly, the hospital started the process for Medicaid for my daughter because insurance life time inpatient stay cap was met. That right there was the beginning of becoming a Medicaid client for my child, and no I was not consulted. It happens in hospitals, and many discharge to residential care facilties *require* SSI for living expenses (rent to them) and that is ran by state funded facilities,which almost seems like a scam…. stated funded care requiring medicaid and SSI before a client is accepted there.

    The medication based paradigm of American psychiatry is the reason why my child ended up on SSI and Medicaid, she became disabled from psychiatry’s pills, which is all psychiatry really has to offer patients isn’t it?

    It’s a reason to get pissed, at pharma, at the medical model we have with pills as solutions, get pissed as a taxpayer if that’s what it takes to seriously ask for mental health reform and alternative ideas and therapies for mental health care, or this will not change. The system is all connected, yet the entities are all dysfunctional and do not truly work with the other. Time for change and a big one at that. Start with less dx of life situations, less medicating life situations.

  21. Anonymouus says:

    Brrr….it’s cold in here. This forum has a pro-anti psychiatry flavor to it as well as a “who can or cannot work the system”. Real mental illness has a severe stigma associated with anyone who owns up to it, I do not have business cards with my name, title and mental illness attached to it. Yet, when well, I work to raise money in the PRIVATE sector (please read no pharma attached) for MI. If you have ever seen real diisabling mental illness, I, as an American, am very happy there is at least something available to keep the deserving of our care and support off the streets. Does the abuse of the “system” make me gag, yes, do I think Doctors need to spend their time playing social worker, no..

    I have worked since I was 12 years old (my choice) in a field where outlandish behaviour is often the norm, It is now 40 years since my first IRS tax forms, do I expect a gold watch when I am 65,,,not! The “system” is so far from perfect and in great need of reform, I have lived in cities that have medicaid checks arriving at mail drops with no address and scamming for wheelchairs, prosthetics, pill mills, ad nauseum. Does it make me nuts to see meth heads mixing up cocktails for human consumption when I never had enough chemistry in school to figure out sea-monkeys! Yup! But, please never forget America was first with its’ disability act and has changed the civilized world in catering to those who are not blessed enough to handle a flight of stairs or the mental clairty to work 9 to 5. Dr Steve I really enjoy your blog, your contributors sometimes, not so much.

  22. A wonderful and troubling topic indeed. “Disability” stirs up questions of who’s to blame, who’s entitled to what, and who may make value judgments about the lifestyles of others.

    I work exclusively in a private office, where each patient makes and keeps his or her own appointments, and usually converses in a more or less articulate way. No florid psychosis or medication-induced stupor in sight. In this setting, which lacks much of the brutal reality of severe psychiatric incapacity, disability seems to me more a state of mind than a cold hard fact. (Surely I’d feel differently in a community clinic, or on the wards of the county hospital.)

    Here, long-term disability status is a symptom — not that common, but not rare either. And from my perspective, a life-limiting symptom calls for understanding the psychological and social factors that gave rise to it, the conflicts and uncertainties that maintain it, and personal strategies for how to move beyond it.

    http://blog.stevenreidbordmd.com/?p=14

  23. [...] psychiatry,” one that requires its own diagnostic system, different criteria for “disability” determinations, a different philosophy of “psychotherapy,” and where medications should be used much more [...]

  24. ellemint says:

    And then there are people like myself, who certainly CAN work in some capacity, but no one will hire us because we have a terrible work history of being fired from jobs, absenteeism, “tardiness” — in my case due to recurrent severe depression over my entire professional life. I can work for a while, initially for 5 years, then 4, then less and less. I just can’t sustain it before I am floored by another episode of major depression—and most jobs don’t allow that kind of schedule. So what am I to do?

    I’m a professional with a PhD, and have now been unemployed for eight years. Only sporadic mental health care because no insurer will sell me health insurance at any price (breast cancer) and the community health care where I live is only available to folks on Medicaid. I am draining my savings but have not had the funds for regular psychiatric care. No one will hire me with my work history and bad references. I could probably work at a job with some flexibility and some ability to work from home, but my experience is that the the high-level positions that allow that kind of schedule (I used to be in academia) are in no way available to me anymore. I’ve been out of the workforce too long and too often. When I apply for low-level jobs (e.g. receptionist), with my professional resume, they look at me with suspicion—they think I’m crazy (which I guess I am.)

    Return to school and retrain in something more concrete? Tried it, — again, intellectually I could handle it, but when I couldn’t get out of bed,–well, I couldn’t follow through.

    I’m not on disability because of pride and an extreme reluctance to throw in the towel. Am I ashamed? Heck yeah. But I am running out of options. Just recently sold my condo and my car. Very soon I won’t even have the required number of successive years of work required to qualify for disability. And for the little “employment” I have had (as a dogwalker, yes indeed), I didn’t even pay in to social security. Despite all that I still am reluctant to apply for disability, and may very well blow my opportunity to do that.

  25. [...] and countless social service agencies also appreciate this “explanation.”)  Finally, as I’ve written about before, many patients don’t see “disability” as such a bad thing; in fact, they actively [...]

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