A doctor’s primary responsibility is to heal, and all of our efforts and resources should be devoted to that goal. At times, it is impossible to restore a patient to perfect health and he or she must unfortunately deal with some degree of chronic disability. Still other times, though, the line between “perfect health” and “disability” is blurred, and nowhere (in my opinion) is this more problematic than in psychiatry.
To illustrate, consider the following example from my practice:
Keisha (not her real name), a 27 year-old resident of a particularly impoverished and crime-ridden section of a large city, came to my office for a psychiatric intake appointment. I reviewed her intake questionnaire; under the question “Why are you seeking help at this time?” she wrote: “bipolar schizophrenia depression mood swings bad anxiety ADHD panic attacks.” Under “past medications,” she listed six different psychiatric drugs (from several different categories). She had never been hospitalized.
When I first saw her, she appeared overweight but otherwise in no distress. An interview revealed no obvious thought disorder, no evidence of hallucinations or delusions, nor did she complain of significant mood symptoms. During the interview, she told me, “I just got my SSDI so I’m retired now.” I asked her to elaborate. “I’m retired now,” she said. “I get my check every month, I just have to keep seeing a doctor.” When I asked why she’s on disability, she replied, “I don’t know, whatever they wrote, bipolar, mood swings, panic attacks, stuff like that.” She had been off medications for over two months (with no apparent symptoms); she said she really “didn’t notice” any effect of the drugs, except the Valium 20 mg per day, which “helped me settle down and relax.”
Keisha is a generally healthy 27 year-old. She graduated high school (something rare in this community, actually) and took some nursing-assistant classes at a local vocational school. She dropped out, however, because “I got stressed out.” She tried looking for other work but then found out from a family member that she could “apply for disability.” She applied and was denied, but then called a lawyer who specialized in disability appeals and, after about a year of resubmissions, received the good news that she can get Social Security Disability, ensuring a monthly check.
How is Keisha “disabled”? She’s disabled because she went to see a doctor and, presumably, told that doctor that she can’t work because of “stress.” That doctor probably asked her a series of questions like “are you unable to work because of your depressed mood?”, “Do you find it hard to deal in social situations because of your mood swings?” etc., and she answered them in the affirmative. I’ve seen dozens—if not hundreds—of disability questionnaires, which ask the same questions.
I have no doubt that Keisha lives a stressful life. I’ve driven through her part of town. I’ve read about the turf wars being waged by the gangs there. I know that her city has one of the highest murder rates in America, unemployment is high, schools are bad, and drug abuse and criminal activity are widespread. I would be surprised if anyone from her neighborhood was not anxious, depressed, moody, irritable, or paranoid.
But I am not convinced that Keisha has a mental illness.
Lest you think that I don’t care about Keisha’s plight, I do. Keisha may very well be struggling, but whether this is “major depression,” a true “anxiety disorder,” or simply a reaction to her stressful situation is unclear. Unfortunately, psychiatry uses simple questions to arrive at a diagnosis—and there are no objective tests for mental illness—so a careless (or unscrupulous) provider can easily apply a label, designating Keisha’s situation as a legitimate medical problem. When combined with the law firms eager to help people get “the government money they deserve,” and the very real fact that money and housing actually do help people like Keisha, we’ve created the illusion that mental illness is a direct consequence of poverty, and the way to treat it is to give out monthly checks.
As a physician, I see this as counter-therapeutic for a number of reasons. With patients like Keisha, I often wonder, what exactly am I “treating”? What constitutes success? An improvement in symptoms? (What symptoms?) Or successfully getting her on the government dole? And when a patient comes to me, already on disability after receiving a diagnosis of MDD (296.34) or panic disorder (300.21) from some other doctor or clinic, I can’t just say, “I’m sorry about your situation, but let’s see what we can do to overcome it together,” because there’s no incentive to overcome it. (This is from someone who dealt with severe 307.51 for sixteen years, but who also had the promise of a bright future to help overcome it.)
Moreover, making diagnoses where there is no true pathology artificially inflates disease prevalence, further enlarging state and county mental health bureaucracies. It enables massive over-prescription of expensive (e.g., atypical antipsychotics like Seroquel and Zyprexa), addictive (like stimulants and benzodiazepines), or simply ineffective (like SSRIs) medications. And far from helping the downtrodden who claim to be its “victims,” this situation instead rewards drug companies and doctors, some of whom prefer serving this population because of the assembly-line nature of this sort of practice: see the patient, make the diagnosis, write the script, and see them again in 3-6 months.
The bottom line is, here in America we’ve got thousands (perhaps millions?) of able-bodied people who, for one socioeconomic (i.e., not psychiatric) reason or another, can’t find work and have fallen upon psychiatric “disability” as their savior. I’d love to help them, but, almost by definition, I cannot. And neither can any other doctor. Sure, they struggle and suffer, but their suffering is relieved by a steady job, financial support, and yes, direct government assistance. These are not part of the psychiatric armamentarium. It’s not medicine.
Psychiatry should not be a tool for social justice. (We’ve tried that before. It failed.) Using psychiatric labels to help patients obtain taxpayers’ money, unless absolutely necessary and legitimate, is wasteful and dishonest. More importantly, it harms the very souls we have pledged an oath to protect.
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I have no doubt there are people who are taking advantage of the ease of a psychiatric diagnosis to get Social Security disability.
It is pathetically easy to go to just about any doctor and come out with a prescription or two for psychiatric medication.
So, “making diagnoses where there is no true pathology” — wouldn’t that apply to most of the people who are on psychiatric drugs now, especially antidepressants?
And don’t forget those who have become incapacitated by the drugs themselves.
Agreed, doctors should have a much, much higher threshold for psychiatric diagnosis and prescription!
http://www.madinamerica.com/madinamerica.com/Anatomy%20of%20an%20Epidemic.html
Whitaker discusses the SSI and dx increase in his book too.
This is a good topic, because people need to realize this is America’s new welfare. The drug companies are eager to supply the force behind the marketing of mental illness in America, the KOLs push it (Koplewicz et al) billions spent on antipsychotics, and mental health screening from toddlers to teens is the beginning of future ‘retirees’.
If taxpayers want to keep track of funding, then they must take a look at who is living on SSI and truly mentally ill or ppl like the one in this story, who argueably are employable, but the system likes cash cows, creates a cash cow, and feeds a cash cow, every time that doctor visit is checked off and the person is still deemed disabled, the system in America is strengthened to support the entire culture.
“There are no objective tests for mental illness.” While technically correct, the a battery of psychodiagnostic tests that I (and others) have administered for the past 40 years in a variety of settings to assess patients is considerably better than only “the simple questions” mentioned. They are often part of disability evaluations.
Steve
“We’ve got thousands (perhaps millions?) of able-bodied people who, for one socioeconomic (i.e., not psychiatric) reason or another… have fallen upon psychiatric “disability” as their savior.”
Where is your data to support this? Show me the numbers.
Even he doesn’t have data, the general point is true. Certainly tens of thousands. What he is describing takes place in every CMHC I’ve ever worked at. It has become a sad joke. Your comment suggests that you do not or have not worked at a CMHC. The fraud and malingering surrounding psychiatric disability is widespread. It’s a known strategy for financial security among many of the lower income “patients” I’ve worked with. The Last Psychiatrist has a nice post about it: In his opinion, it’s not fraud, but, as stated above, an intentional welfare program. Cynical, yes, but I think there is something to it. For 600 dollars a month, you keep them from rioting.
Dr Johns,
That is a good question. Data are essential, and I, like you would love to see the numbers.
Unfortunately, any “numbers” are most likely tainted by precisely the phenomenon I described in this post (and which Gary describes in his response). This is one reason why Whitaker’s chief premise is, in my opinion, faulty: he sees rising “disability” as a consequence of psychiatric drugs, whereas I have seen it (first-hand) as a justification for the use of those drugs in the first place.
I’m simply reflecting upon my own observations in two clinics in two counties in California. Several of my “disabled” patients are not disabled, diverting resources from the subset of my patients who truly cannot and will not be able to work. If my observations can be generalized to community clinics across the country, I would imagine the “numbers” are huge.
So, I work at a CMHC (fortunately not a med-mill) in northern California. and I’ve seen fraud. But, as long as we’re talking about general impressions and not hard data, my best guess is that fraud occurs in a small percentage of cases. I have seen a few patients who collect SSi without being truly disabled, but they are tiny minority. Whatever the costs of this failure rate, it pales in comparison with the “massive over-prescription of expensive” medications by psychiatrists for patients who are correctly diagnosed and and compensated.
http://www.psychologytoday.com/blog/mad-in-america/201102/disability-in-the-age-prozac
Robert Whitaker
“In my book Anatomy of an Epidemic, I investigated this puzzle: Why has the number of adults on government disability due to mental illness soared since Prozac’s arrival on the market in 1987? Prozac was the first of the “second-generation” psychiatric drugs, and our society’s use of these medications has exploded since that time, which presumably should result in a lessening of the burden of mental illness in our society. Yet, from 1987 to 2007, the number of adults on federal disability due to mental illness rose from 1.25 million to 4 million, begging this question: Could our drug-based paradigm of care be fueling this epidemic?
That, of course, is a provocative question, and I spent 260 pages in Anatomy of an Epidemic seeking to answer it. But recently, I came upon two new data sets that, at the very least, add new reason for our society to worry about this question.”
Why could not the rise in disability due to mental illness be caused by multiple factors? There could be malingering (always present in Social Security disability) AND in another population, it could be a consequence of medication.
Still, I think Whitaker’s question is still a good one. A corollary is, “If our drug-based paradigm of care is so good, why aren’t more people cured by it?”
I’d like to point out again among the more than 30 million Americans on psychiatric drugs, 90% are on antidepressants, which have a very poor remission rate and increase the risk of truly chronic diseases, such as diabetes, which on their own cause more cases of disability and shorten lifespan.
As Whitaker explains, calling depression “chronic” may be merely a construct to justify the lack of medication efficacy. Most patients would probably have a higher rate of recovery and better quality of life if left unmedicated. Another bout of depression in the future? They’ll recover from that, too.
Our culture is twisted towards expectation of constant happiness and productivity. This may not be consistent with the human condition. After risk-benefit analysis, not every case of depression deserves medication, even if identified by putative diagnostics.
When I was in medical school in the late 1970’s, we were taught that the natural course of depression was remission, with or without treatment. This conclusion was based on natural history studies of patients followed over time. About 10 years later, this all changed. Once Big Pharma and the DSM revisionists (expanding major depression, for example, to encompass just about anything) got in the game, everything changed. Why the new view was you needed antidepressants to function, and that you had to stay on these agents for the rest of your life, lest you fall prey once again to the dark beast. Hell, social phobia became a fad diagnosis, treated, of course, with SSRI’s! It was all a crock of shit, dreamed up in the marketing divisions of Big Pharma with academic psychiatrists (e.g. KOL’s) paid (or bribed) to send this bullshit message to the masses. I have no idea if the chronic use of antidepressants results in disability. I leave this to my research colleagues to answer. I see fully the need for medication in acute, severe depressive episodes; but the rest is blarney.
I sure wish your research colleagues would answer whether the chronic use of antidepressants results in disability. Here’s the results of one study:
Depression and Incident Stroke in Women http://stroke.ahajournals.org/content/early/2011/08/11/STROKEAHA.111.617043.abstract
It looks to me like the two groups on antidepressants, depressed or not, had significantly higher stroke risk while the unmedicated depressed group had normal stroke risk. To me, that would indicate the medication raised stroke risk, but the authors concluded that it was DEPRESSION, not medication, that increased strokes.
Have I misinterpreted the findings or did they bend over backward to whitewash the meds? Or did the involvement of Harvard psychiatry somehow influence the conclusion?
It is not easy to get ss disability. You need to be considered disabled by the state’s doctors as well as your own. I am sure there are malingerers who have been able to fake their way onto it but please do not continue this old wive’s myth that it is a simple thing to do. The more simple thing is being able to stay on it since disability does not do a good job on following up to assure the disabilty continues.
I would think that for all the reaosns others have mentioned, that a psych disability might well be easier to get because a lot of psych diagnosis is based on self reporting.
Carol,
Thank you for your comment. It is indeed a strange paradox that patients with certain physical ailments (including chronic pain and conditions like fibromyalgia, which can, at times, be quite debilitating) have a difficult time qualifying for disability, whereas many able-bodied individuals seem to get disability benefits with relative ease.
I agree that “ease” is relative. But, as I’ve been told by several seasoned clinicians in my current county clinic, persistence pays off, and “anyone who resubmits often enough will get approved.” This, combined with the facts that (a) psychiatric symptoms are entirely subjective, (b) many physicians err on the side of over-diagnosing and over-treating (which gives the impression– to a judge or lawyer, or indeed to another MD– that the person is more disabled than he/she actually is, and (c) an entire industry of attorneys (who advertise on daytime TV) are more than eager to help, means that if someone needs the money, he or she can get it.
The more insidious aspect of this whole process– and one which I tried to emphasize in my post– is that once a person is granted disability, it makes the whole concept of “treatment” moot. What am I, as a psychiatrist, supposed to do when I firmly believe a person can overcome their disorder (with or without medications) and lead a relatively functional life, but they are satisfied with their current situation? It flies squarely in the face of everything I have been taught as a healer.
If, instead, the system wants me to serve as a patient’s “benefits manager,” fine, but as a doctor, I command much too high of a salary to make this an efficient means of distributing welfare. Moreover, it’s a slap in my face to call it “medicine,” even though many of my colleagues (some knowingly, some not) think that it is.
I wonder if it is possible to notify social security, telling the patient you will do so (Hippa and confidentiality may well prohibit it but since the money is gov;t money based on the psych Dx maybe not an issue.) that you do not believe they are disabled.
As someone on SSD due to trigeminal neuralgia I am disturbed there is not more follow up (I know people on it who are making a living (under the table”) and routing out the able.
You do need to have 2 state doctors declare you are disabled (at least that was case when I went on it.) so I am somewhat surprised at the ease that you mention. It is disturbing also that a lawyer can get you SSD when you are not able to do so yourself relying on your medical history and present condition.
I went to appeal 2x over the years. It was difficult but I had no attorney and let my situation speak for itself. When the judge asked me :Why don’t you have a lawyer?” I replied “Because I know I am telling the truth”. Although it is not always the case, esp with people with chronic pain disorders, the truth should be sufficient.
Why are there so many blog postings by mental health professionals about people on disability who aren’t disabled, but never a posting about how people who ARE disabled often feel useless and ashamed that they cannot work? How they may have to change WHO they are, because in this country, your work is often your identity? Or about how if you have severe and chronic mental illness, the disability paperwork is overwhelming? Most people I know on disability need a social worker to help them with paperwork. In a country where you are supposed to work hard, where does a chronically mentally ill person fit in when they can’t consistently make dinner or mop the floor? Work brings dignity, but what if you can’t work? Should you be made to feel ashamed of yourself? You have no dignity because you don’t work and can’t do your chores around the house, either?
Why are these kinds of topics never addressed anywhere?
Because it is easier to write judging posts than it is to write compassionate posts?
It isn’t this post specifically that is the issue, it is the aggregate of so many posts and articles and comments in the general public, etc.
It would really help (me, at least) if instead, someone somewhere would write a blog post about how to cope with the loss of identity that happens when mental illness forces you onto disability. About how you have to keep your mental illness a secret, because so many people hate and/or fear people with serious mental illness, and how do you do that, when you are disabled and people ask what you do for a living and so on. How to cope with the shame of not being able to keep up with your chores, so your home looks like a total pit when people come over to visit.
But the everyday struggles of living with the disability of mental illness isn’t as interesting as fraud. And I also get it that there are a lot of people with mental illness who do not care about the issues that I mentioned, but plenty of people I know have the same struggles that I do.
(I appreciate how carefully your wrote your article, and this wasn’t a rant against your posting specifically, but rather about how so many people are going on about everybody defrauding social security disability.)
There’s a very long YouTube video including addresses by David Healy and Robert Whitaker (Anatomy of an Epidemic) at http://www.youtube.com/watch?v=5bu1uApqIr4
Robert Whitaker starts at about 1:30. He says the huge rise in US mental disability is due not to psychosis but to depression and bipolar disorder, and further traces it to iatrogenic illness.
Iatrogenia. Malingering is “always” present in ss disability? Where did you come up with that one?
Pat, you comments are right on target. I need to let you know that for many who are disabled, from ‘invisible’ illness your words ring very true: the loss of identity, keeping your illness a secret, because people do not want to accept/believe the truth and debilitation of (psychiatric, pain, other disorders). What you do for a living an awful question that many work hard to avoid being asked. (Especially when you run into people you used to know from your ‘old’ life.), how to cope with the shame of not being able to keep up with your chores and self. Shame is not a word necessary when the disability can be seen – crutches, wheelchair, other visible indices of informity. It should not be a word when the disability is invisible.
Psychiatric illness is still a disorder that people want to keep hidden in the closet, much more than others, and the shame lies with those people and society as a whole and not with those who are disabled by reasons outside of their control.
Throughout the history of Social Security Disability, there have always been some individuals who posed as disabled to get benefits. That is why they have independent assessment.
I did not mean every person who get SSD is malingering, just that people taking advantage of the system is not particular to mental disability.
Even if people are “disabled” from their mental illnesses, our first job as mental health professionals should be one of facilitating recovery, not encouraging more to join the SSI rolls. In the pre-neuroleptic era, the severely mentally ill proved they were capable of working in the state hospitals, albeit under coercive conditions. Obviously, I’m not advocating a return to that; but the point is, that even in an untreated state, they were capable of employment. The mental health system as a whole promotes dependency and the sick role in its wanting subjects, whereas other models of care, such as in the addictive disorders and developmentally disabled systems advocate employment as a major treatment goal in the recovery process. Sadly, many mental health “providers” (not professionals) want to maintain the status quo of an unhealthy symbiosis, wherein both parties end up padding their pockets, with the providers being the far larger beneficiaries.
Agreed, and the goal of psychiatric care should be to get the patient off medication and dealing with life as autonomously and capably as possible — not to be undermined by spurious diagnosis and unnecessary, debilitating medications for life.
This is particularly applicable in depression, which constitutes the vast majority of psychiatric diagnosis.
This is a great topic, quite nuanced yet so important to psychiatry as well as society as a whole. I recently started seeing a woman who introduced herself as having about 6 psychiatric diagnoses. She’s on psych disability. Yet she previously worked in a variety of jobs, and seems no more impaired now than she’s ever been. Although quick to temper, she doesn’t evidence any obvious mental disorder, and seems well within bounds of what most would call normal. I’m happy to say that she tolerates my talking to her as a person instead of as a collection of symptoms and labels; the real test will be when her disability re-eval comes due. I’m already trying, gently, to introduce the idea that these labels and disability status don’t serve her in the long run. But it’s an uphill battle against the obvious (and less obvious) benefits she accrues.
I don’t know if this can fairly be called a widespread phenomenon, or just especially memorable when it appears. Either way, it highlights our mixed feelings about entitlement, dependency, and compassion as a profession and as citizens. For a few more thoughts on this topic see:
http://blog.stevenreidbordmd.com/?p=14
I think I was 27 when I thought about “retiring.” I’m 62 now. But I had recently come across a group of people who didn’t have to work. One was retired military, and his youngest son was on SSI for dyslexia. They were basically drinking buddies and great fun. Through them I met other nonworkers, and began to notice the number of people around me who seemed normal but with no visible means of support.
Another young hanger-on admitted she was attracted to the lifestyle, too, and did eventually get on SSI for “mental” as she called it, because it was the easiest route to go. But her life went downhill and she went from charmingly normal to drug addled drama queen. I wonder if she felt she must live up to her diagnosis?
In fact it seems like a lot of them go downhill, once they decide to play that role.
re testing: I wrote a blog post a few days ago about the MMPI. http://apainedlife.blogspot.com/2011/08/mmpi-valid-not-for-pain-patients.html
Many of the questions are invalid for instance, for someone with chronic pain. In addition, the results can certainly be changed by the testee, many of the choices obvioous as to what is ‘right’ and what not, and that included easily being aware of the ones that are worded to validate earlier responses.
I am not putting down your life’s work of testing but many tests, TAT, DAP, etc can be faked to get the diagnosis if one is looking to be certified as psychiatrically ill (or not if you are healthy enough to discern what is required.)
WWanda, even those not on SSI, SSD can play the role of disabled, physically or psychiatrically, and then sadly the role defines and becomes them. (I have seen this in my family)
Leej, it is difficult to fake on the MMPI, or Millon for that matter. Both have validity scales…so-called F, K, and L on the MMPI, and disclosure, desirability and debasement on the Millon. Without going into much detail, suffice it to say, that there are fairly sensitive indicators for detecting “faking bad” or “faking good” profiles on both of these, as well as downright malingerers in unsuspecting subjects. Overall, these are underutilized by the Social Security system, and could be invaluable as an additional tool in decision making, particularly in individuals in which there is a significant disparity between objective observations and subjective complaints within the context of a potential secondary gain agenda.
I took it twice, online, and when I changed my answers to comply with my disability and then to not, the results were different. The issue of malingerers is the most important to me as the answers for those of us, for instance, with chronic pain
“I wake up fresh and rested most mornings.
My daily life is full of things that keep me interested.
I am about as able to work as I ever was.
I work under a great deal of tension.
I am sure I get a raw deal from life.
I am very seldom bothered by constipation.
I find it hard to keep my mind on a task or job.
I am a very sociable person.
Parts of my body often have feelings like burning, tingling, crawling, or like “going to sleep”.
Other questions, “I feel blue much of the time.” etc
are right on target for many of us but indicate deprression, malingering etc .
Unfortunateky pain is invisible and, as with some psychiatric disorder, subjective.
I was given the MMPI as part of an evaluation when Dr. William Sweet was trying to talk me into a mesenphalic tractotomy or mini-frontal lobotomy because of the severity of my pain. “You will still have the pain, you just won’t care that you do.” He wanted the results to show psych disturbance such as depression as his excuse for doing the surgery.
Without factoring in the reality of my pain, he got the results he wanted. Factor them in and the results do not show the same depressive results.
The problem is the person who suspects secondary gain as a motive is going on his own subjective evaluation (and possibly agenda).
leej, there are some clear red flags to raise the suspicion of an examiner for malingering, apart from obvious dissimulation from psychological testing, including disparity issues that I’ve already mentioned, noncompliance with the evaluation and treatment process, a history of antisocial personality disorder, and clear potential for conscious secondary gain (distinguished from primary gain which is unconscious, and associated with somatoform and factitious disorders). You’d be surprised by the number of requests for records we receive from the SSA for patients we’ve never seen, only to evaluate them subsequently and discover that almost uniformly that they have a clear agenda to use the mental health system to support their disability claim.
I understand your position. My only concern to your reply is when you write “almost uniformly they have a clear agenda…” I don’t know – it sounds like you have an agenda. I do not mean that disparagingly but whenever I read what sounds like bias I do have to question objectivity.
leej, in the quote from me that you referenced, I was only referring to a subset of “patients” who have applied for disability even before attempting to get treatment, and they fortunately only comprise a small percentage of my practice.
Steve, I am sure your intentions were good but I find your blog headline, “Retiring at 27” extremely inflammatory.
It is not like people are getting rich on disability. Also, while many people get it who may not deserve it, there are folks who try repeatedly who do deserve it, who don’t get it.
There also seems to be a cognitive dissonance in various posts. What I am hearing in the message from psychiatry is that people are defining themselves by their disability and thus see themselves as unable to work. As result, they apply for disability.
But on the other hand, when people, including me, told their psychiatrists they wanted to get off of meds, we essentially were given the message we needed them for life and were powerless over our conditions. We were not applauded for taking control of our lives.
Anyway, it seems psychiatry is not consistent in their attitudes regarding people seeing themselves as non disabled and that bothers me greatly.
AA,
I, too, found the statement about “retiring at 27” inflammatory, and frustrating. But remember, it came from a patient, not me.
I know nobody “gets rich” on disability, but plenty of people can live on it. (Actually, to read a more thorough argument of this point, see this post on The Last Psychiatrist.)
Like you, I also experience the “cognitive dissonance,” and if you read it in my posts it’s only because I’m trying to demonstrate the absurdities of what I see and do every day. I know that mental illness exists, I know it (frequently) can be treated, and I agree that the unfortunate standard of care in this field is to see disease as chronic. At the same time, I see plenty of what I would argue is not mental illness, but which has been labeled as such by well-meaning (and not-so-well-meaning) doctors and which, ultimately, robs patients of any hope for a better future (but ensures a monthly check).
“”I, too, found the statement about “retiring at 27″ inflammatory, and frustrating. But remember, it came from a patient, not me.””
You are correct and I apologize for that.
“”I know nobody “gets rich” on disability, but plenty of people can live on it. (Actually, to read a more thorough argument of this point, see this post on The Last Psychiatrist.)”
That would be quite hard to do in my area.
Finally, one of the problems that may be contributing to people applying for disability who perhaps could work is that job hunting services for people with disabilities and other disadvantages are in the dark ages.
Showing people how to search for ads on popular job sites is not my idea of creative job development, especially when for people without problems, that has about a 5% success rate.
I know that is outside your area of expertise but is something that folks in psychiatry need to be aware of.
Bravo, Dr. Steve! You are exactly right, that labeling of mood disorders as “chronic” disenfranchises and demoralizes patients, making them dependent, literally and figuratively, on pharmaceuticals — but it has long served its intended purpose, which is to justify the long-term prescription of psychiatric drugs.
So, on one hand, we have doctors telling patients they have a “brain disorder” (the current jargon, implying degeneracy) that will need eternal medical attention and on the other hand, complaining when they view themselves as irreparably damaged.
For what it’s worth, I often tell patients my goal is to make myself obsolete. I agree that many psychiatrists over-sell the diabetes/hypertension metaphor to justify endless treatment. On the other hand, some patients who really are disabled are in denial, such as one patient I saw who wanted to quit his meds despite being mildly psychotic and unable to return to college. The devil is in the details.
SteveB was quoting his patient who declared herself retired. But if there’s anger or frustration in his tone — I don’t “hear” it myself — it wouldn’t be hard to fathom. Undue entitlement and unfair advantage almost universally provoke anger in others. Here in San Francisco there are huge numbers of cars sporting disabled placards, giving them free parking at meters. In a city where parking is in short supply and quite expensive, there is growing resentment over “gaming the system” to obtain these placards. Likewise, in this economy it isn’t surprising that a self-professed retirement based on dubious entitlement garners more attention than the opposite problem of people who need a disability status and aren’t getting it. As I wrote, the phenomenon may be more memorable than widespread.
“”For what it’s worth, I often tell patients my goal is to make myself obsolete. I agree that many psychiatrists over-sell the diabetes/hypertension metaphor to justify endless treatment. On the other hand, some patients who really are disabled are in denial, such as one patient I saw who wanted to quit his meds despite being mildly psychotic and unable to return to college. The devil is in the details.””
I am glad to hear you say your goal is to make yourself obsolete.
However, I have another take about your patient who is mildy psychotic being in denial who wants to quit his meds.
Maybe he finds the side effects intolerable and as a result, feels too cognitively impaired to return to college. You might want to google Pat Deegan, a clinical psychologist who was hospitalized 8 times for schizophrenia who talked about the patient vs. the psychiatrist perception regarding meds.
Anyway, as one who has seen up close and personal the devastation that antipsychotics has caused to someone, I don’t understand why psychiatry continues to see this as an either or issue.
If the patient wants to stay on the meds, that is fine but if he doesn’t, then in my opinion, he should be supported with a very slow tapering regimen and other options that might be helpful such as fish oil and a gluten free, paleo like diet.
CBT can also be very useful.
I am getting too much off topic which I apologize to readers for. But this obviously is a hot button issue of mine.
To the rest of the points that you made – Yes, people focus on who is gaming the system but that doesn’t mean it is right since many times, the reverse situation is alot worse.
Also, people are very judgmental.
One time, I drove an elderly relative who had a handicapped sticker. I got out first so I could help her get out of the car and if looks could have killed, I was a dead duck.
It was only when she got out that people stopped glaring at me.
First you slam SteveB for creating an inflammatory headline and being responsible for the very “cognitive dissonance” that he routinely highlights in this blog. Then you suggest I may be ignoring intolerable side-effects in my patient. These assertions are pure fantasy. If you truly seek to reform psychiatry, or any institution, it’s best not to alienate your allies.
Just posted on YouTube:
Career Exploration: The Professional Psychiatric Patient (Part One)
Candidate interviews for professional psychiatric dehabilitation services.
Wow Dr. Reidbord, how is calling someone’s assertions fantasy contributing to this discussion? That is extremely insulting.
I apologized to Steve for my mistake. Somehow, you conveniently overlooked that.
In my response to you, I suggested that your patient might find the side effects intolerable and was the reason he wanted off the meds as an alternative explanation to being in denial about his condition.
I am sorry if that unintentionally struck a hot button issue of yours but there was nothing offensive about that statement.
I also mentioned another reason for my concern was having seen up close the devastation that antipsychotics has caused someone. Instead of seeking to understand that perhaps I had reasons to say what I did, you chose to discredit me by calling everything I said pure fantasy.
And psychiatry wonders why people are so angry at the profession?
Please, peace among the allies!
I applaud Dr. Reidbord for his goal of making himself obsolete. Would that more psychiatrists had that goal.
I also believe the patient’s wishes to get off medication should be respected. Mental health treatment should always aim towards autonomy, self-respect, and the direction of individual will to self-healing. It’s a tragedy that the current medical model of psychiatry does not include this.
Dr. Reidbord may well be trying to balance respect for his patient against what he perceives is a real need for intervention.
Personally, I always read a great deal of irony in Dr. Steve’s articles, which I greatly enjoy.
One need only read Thought Broadcast a little to know that Steve doesn’t denigrate patients, and that he aims to shine light on “cognitive dissonance” in psychiatry. If in response you come out swinging, the fight is inside your own head, i.e., fantasy. Similarly, you assume without evidence that I’m professionally incompetent and insensitive… and yet I’m the one who’s “extremely insulting”…
You assume I pressured my patient to take noxious meds. Actually, I tapered him off his neuroleptic. My idea, not his. (He’s also on a mood stabilizer and I thought/hoped it would suffice.) He returned a week or two later frankly psychotic and *asked* to be hospitalized. He’s now on a higher dose of neuroleptic — thanks to the inpatient docs, but I’m not complaining — and doing much better. Yet he’s in denial: He saw yet another psychiatrist recently hoping she would not diagnose him as his previous 3 or 4 have. She did though, because the facts are the facts.
If I made a mistake in his case, it was by being overly in your camp, not the other way around. Maybe that’s why your comment particularly irritated me. Anyway, we’ve digressed from the topic of unwarranted psychiatric disability status, so I’ll leave it at that.
Stop with these psy. Same problem in Switzerland.
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[…] don’t see “disability” as such a bad thing; in fact, they actively pursue it—sometimes even demanding this label—despite my attempts to convince them […]
I receive a total of $9,298.00 tax-free income a month from private disability insurance, VA disability, and SSDI. I have no debt, invest 5-6K a month in stock and live very comfortably. I have an attorney who fends off attacks from the disability insurer and the government. My question is ” What’s the incentive to try and get back into the workforce? ” The answer – none. There is absolutely no reason. Corporations don’t give a damn about their employees anymore, its all about the stockholders. When you turn 50, most companies don’t want you anymore because you’re either making too much money, costing them too much in healthcare, or both. People get chronically depressed because they can’t find work. So, who’s really to blame here? Health and disability insurers complain that their is too much insurance fraud and it needs to stop. But at the same time, these same insurers are deny legitimate claims to unsuspecting policyholders who don’t understand their rights, withholding benefits to maintain profits and satisfy the stockholders. The whole system is a total joke. Most people don’t even know about ERISA, and how difficult it may be to get your disability benefits. I suggest all of you read up on it. The point is, that disability policy you’ve been paying $10.00 every paycheck by automatic withdrawal isn’t worth crap. ERISA severely restricts the policyholder’s ability to recover damages in the event that the disability insurer deny’s your claim. In other words, they have almost complete discretion in deciding your claim, and in the majority of cases, you can’t recover damages in federal court, no matter how legitimate your disability claim is, that’s why its so cheap. People think they’re protected by this crappy insurance and they’re not. I laugh like hell when I see these ridiculous AFLAC commercials. They show people swinging in a hamic having an outdoor bbq telling each other life is good because they’re protected by this disability insurance. Its all a scam. The truth is they will fight you tooth and nail to avoid paying your claim. Most people don’t have the resources to fight these insurance companies and the insurers know it. So, the claimant eventually gives up. I’ve given up trying to go back to work, its just not worth it….
I’m almost 55 (4 months from now), really do have many of the same issues as the 27 year old in the story, and was denied on initial application for SSDI and have a bad feeling I’ll be denied again in a year or so when I get my appeal hearing. How do these people with “nothing” wrong with them get approved when someone my age with actual lifelong problems can’t?
I have been to the mental hospital multiple times through out my life and increasingly since 2010-2012. I started receiving checks In dec 2011.I am ashamed of my self and want to work again.I am now seeing therapist and psychiatrist. So hopefully I get a job before they discontinue the money for my survival/ existence.
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well you got atleast one part wrong.. SSDI is money that I paid into for 22 YEARS working in the coal mines.. It pisses me off to no end when people say Im living of their taxes.. uh NO!! Im not!! I paid thousands of dollars into this INSURANCE program..its my money..not YOUR TAX dollars..if you claim to be so smart..you think youd know that!
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How To Retire At Age 27 | Thought Broadcast
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Many people who are mildly mentally impaired are railroaded into the mental health system . They are forced to take drugs wich are debilitating and keep them from doing every day task like driving a car in a safe Maner. Most are unable to work as a result of the poisons . So they are forced to collect ssdi. It seems that yes these people who are mildly mentally impaired do need assistance . The mental health center is seen as a place to help these people this makes matters worse. The mentally impaired need other supports like employment supports. Mony is wasted on this psudoscience and ssdi when all these people need is help getting a job maby there should be an enployment agency for the disabled and not all this phony deadly medical business
Ridiculous. Im young and look ‘Normal’.
I sleep 1-2 hours a night about 3 days out of the week. Other days is 4-5 if im lucky. Taken over 20 medications to help for panic attacks anxiety, depression, etc. My life has been hell. How dare you judge someone because theyre young and the way they look.
I hear what you’re saying but I am bipolar, over the last few years it has gotten way worse but I can not afford to go to a Dr on a regular basis. I can’t seem to hold down a job, I have come to hate people and hate leaving the house, unless I’m with my husband. No matter how hard I try to be positive I hate everything about me. Idk what to do seeing how we have bills and can’t afford for me to go to the Dr but yet can’t get financial assistance because my husband makes too much. It’s so unfair how everything is put on him when I don’t work and we do have bills.
I do believe with how I am that I do qualify for some assistance but I can’t afford going to a Dr to back me up. Ugh
We all have bills. I have extreme pain in my feet every day from years of working as a nurse yet I still…go to work every day to pay MY bills because they are MY bills. I don’t expect the American tax payers to pay any of my bills.
GET OVER THIS SHIT AND GO TO WORK…LAZY …YES LIFE IS TOUGH..BUT THE WORLD DOESN’T STOP FOR YOU OR ANYBODY ELSE BOO FREAKIN HOO
I’m sorry. I have a hard time believing that this story happens often. IMO, it clearly has an agenda. He uses the name “Keisha,” knowing full and well what this implies, especially given the neighbourhood scene. It’s a nice way of contextualizing the content while remaining unbiased. You essentially want us to know this is a “welfare queen”
The truth is that most stories are not like this. Lawyers often won’t even take anyone in this age bracket, and they certainly don’t take people with weak medical histories. If they do, it’s rather rare, and it’s because they don’t care about Keisha, LaTonya, etc., they care about money.
The absolute first thing any lawyer requested from me was my medical history. Mine was profound enough (7+ hospitalizations) to get one.
If you guys believe that this story is real (I have doubts due to the contextualization), please call up your most hated law firm and tell them this story.
I work as a psychiatric nurse at a hospital and I’m telling you that this happens ALL the time. It’s disgusting. We should not have to support fakers.
I am on SSDI because of MS. To me, one of the worst aspects of my situation is NOT being able to work. 1) I liked to work, even though most of my jobs, (before I educated myself), were mundane. 2) I made much more money working. Mankind does not need all of these drugs for anxiety and such, we made it to this point didn’t we? I think anxiety is necessary to maintain healthy cognitive function.
These people, and I’m saying that because of Keisha’s physical description, the description of her part of the city, the gangs and an impoverished school district represent the population whose manual labor is no longer in demand. There is an oversupply of cheap exploitable labor in America today and its projected to become much worse for those who only market their warm bodies for labor. McDonalds and Burger King come to mind with their vending machine type service which cuts out a need for cashiers and the others in the assembly line service jobs. Another example is one person overseeing a team of robots doing what an entire shift of humans formerly did.
Poverty like wealth is a direct consequence of a capitalist society. Poverty benefits the elite ruling class. It ensures there will always be a supply of cheap labor. When there is an oversupply of cheap labor, the Kiesha’s of society are over represented. They will riot, commit crime, form gangs and be contained in a part of the city that is out of the way. These communities are spatially disconnected from the thriving areas.
To dole out traditional welfare is actually a way of increasing this population. It is no secret this population will have babies to get on welfare, food stamps, and a housing voucher for low income housing. (in that part of the city).
I believe the author is inaccurate when saying Keisha is collecting SSDI benefits. Keisha’s age 27 and being of her description indicates to me that she does not have 40 credits (10 years) of continuous work history. Keisha most likely collects Supplemental Security Income or SSI benefits. A psychiatric disability is treated with drugs that shut down the libido hence no welfare babies out of her. The psychiatirst prescribed drugs that shorten ones longevity. Psychiatric drugs make one docile, hence a less threat of violence. The economic benefit of this type of population control is in fact a necessary expense to society as a whole.
The author, purportedly to be a psychiatrist undoubtedly knows all this to a perfection that I don’t have. A liberal arts undergrad is schooled in economics, sociology, philosophy, and other behavioral sciences. I’m not surprised she would write such an article as this to merely point out the flaws of capitalism.