Disability forms and entitled patients

[countryboy75]

As part of my training in residency we work a 6 month community mental health rotation. For the most part I enjoy this, typically it is patients who are on medicaid or another susidy program that thay have here and they tend to be people who genuinely want and need help.

However, as of lately I have been feeling some deep issues of countertransferrance and generalized frustration with a number of my patients. I understand the economy is not the best it has been, jobs are not in abundance and people are having a difficult time getting by. But, I am appalled at the number of otherwise healthy patients who come in here seeking disability from their first or second visit. I can understand they have depression, I can understand they likely have sxs of borderline or antisocial personality disorder and they do play a role in them having a difficult time seeking employment but where do we as psychiatrists and as society draw the line in what disability is? And since when are psychiatrists the ones to essentially tell people "ok, you shouldn't do anyhting, you should sit on your butt at home and collect a monthly check" instead of "I have multiple treatment options we can explore and we can eventually work towards getting you back into the workforce"

When I try to do the latter I suffer some form of repurcussion whether it be a formal complaint against me or a request for a change in provider or the patient just stops coming in to see me. Or I even have social workers who will contact me and send me on a guilt trip about how hard the patients life is.

Like I said, I understand there are those who need disability but I also think metaphorically speaking that we shouldn't feed the bears. If you go to the national parks and you feed a bear you will be given a citation, reason being that the bears give up on learning how to hunt and forage. Is disability in theory feeding the bears?

Those of you in residency are you often required to fill out these forms?

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[billypilgrim37]

Around here we tell patients they can contact medical records to get their information, and that they would be best served by pursuing an independent medical evaluation for their psychiatric assessment for disability. Some get mad and/or complain, yes. That's okay. You're going to be dealing with complaints your whole life. If they're complaining about you doing your job well (and I would argue that not filling out their disability work as their TREATING psychiatrist is part of that), you're going to be okay 99/100 times. And the 1/100 probably won't be so bad either.

That's not to say I haven't had borderlines throw things at my head because of this. But fortunately most borderlines throw like girls.

 

[whopper]

Some evaluations can be done by the treating doctor. Depends on the person and organization such as the government or private disability. Others require a neutral/nontreating doctor.

A problem that often arises is malingering and that as treating doctors, we have a bias for the patient. Others-countertransference.

What really bugs me is when the patient asks me to fill them out literally just a minute left in the interview and those things can take a long time get done.

If I ever do one that I'm supposed to do as a treating doctor, I pretty much always state something to the effect that as a treating doctor, I feel that I have a treatment bias for the patient and that a better evaluation would likely be better done by non-treating doctor doing a forensic level investigation.

 

[billypilgrim37]

Some evaluations can be done by the treating doctor.

CAN is the operative word. Doesn't mean you have to do it if you have a policy that says you believe such things are best done by someone independent.

 

[OldPsychDoc]

"Are you the Disabilty Doctor?"

 

[countryboy75]

HA HA HA HA, I love that movie, I needed that.

I like the idea of requesting a forensic psychiatrist eval

 

[OldPsychDoc]

I like the idea of requesting a forensic psychiatrist eval

Sometimes if you have access to an Occupational Medicine department they will help as well.

 

[shan564]

"Are you the Disabilty Doctor?"

Ha, yeah, sounds about right.

 

[birchswing]

I don't really have anything to say except that I think this paradigm being discussed is much more complicated than represented in that video, and viewing the issues of health, psychiatry, and disability in a reductive way is probably not helpful. People generally do things because they want to be happy, in that way, we can see what others do as being related to why we do things, as well. I think there is an earnestness to almost all actions we take, regardless of how we view others' actions. That's not to say you can't want something more for someone else, which is kind.

 

[shan564]

I don't really have anything to say except that I think this paradigm being discussed is much more complicated than represented in that video, and viewing the issues of health, psychiatry, and disability in a reductive way is probably not helpful. People generally do things because they want to be happy, in that way, we can see what others do as being related to why we do things, as well. I think there is an earnestness to almost all actions we take, regardless of how we view others' actions. That's not to say you can't want something more for someone else, which is kind.

I think we all realize that. For most people, disability is a last-resort refuge, and I encourage those people to pursue this option. But we've all dealt with the malingerers who have voices that wake them up from sleep and the only thing keeping them from working is the fact that they refuse to try to cut down on (insert substance here).

 

[nancysinatra]

There was a good public radio story about this recently. Since the states decreased welfare funding under President Clinton years ago, millions more Americans have been applying for federal disability. Some states have even hired consultants to help them purge their welfare rolls by encouraging people to apply for federal disability. States with crappy welfare benefits are being subsidized by those of us in other states where the state benefits are better.

There is no government push back on disability applications. In other words the government has no lawyers to contest disability applications! So for a persistent applicant, the likelihood their application will be approved is very high. Entire law firms specialize in this area. Whether it's lower back pain or depression a person can very easily get disability if they persist. Hence we see so many people on disablity or applying for it!

So I don't really blame the patients per se. Pursuing disabilty these days is no more a sign of "entitlement" than applying for food stamps or welfare once was. If you're unemployed, and out of money, and your education is substandard, what else can you do? There's a whole culture of Americans who don't seem to "be able to work." If you ask me, if you are a psychiatrist and are deeming victims of the economy to be "borderline" or "antisocial" or "entitled" -- then that is your countertransference and your own political mindset speaking. Ultimately at some level it is the fault of our economy and our school system that people aren't employed, whether it's because we don't train people, we don't have jobs, or we don't simply let people starve if they can't fend for themselves.

I too hate these things, and I feel very bitter about them. But that's just me. The way I approach them currently, is I agree to fill them out. And I say the truth! I say that the patient stands a good chance of recovering if they continue with treatment. I don't care if they get mad. I usually write in "I don't know" to any questions about whether they can work or not and for how long.

I have yet to have a patient come in with a form who actually IS disabled. A severe schizophrenic, say. I don't know what I will do then.

 

[whopper]

Excuse my little rant.

I have an aunt-in-law that is a right wing conservative, calls people on welfare losers, is a Limbot, pretty much repeating anything the guy says without thinking about it on her own, thinks Obamacare is a waste because no one is entitled to government assitance for their health problems, has a vacation home in Costa Rica, has a husband that makes good money, and guess what? She's on disability.....

For Fibromyalgia.

 

[birchswing]

Excuse my little rant.

I have an aunt-in-law that is a right wing conservative, calls people on welfare losers, is a Limbot, pretty much repeating anything the guy says without thinking about it on her own, thinks Obamacare is a waste because no one is entitled to government assitance for their health problems, has a vacation home in Costa Rica, has a husband that makes good money, and guess what? She's on disability.....

For Fibromyalgia.

You can't buy self-esteem like that!

 

[SteinUmStein]

Excuse my little rant.

I have an aunt-in-law that is a right wing conservative, calls people on welfare losers, is a Limbot, pretty much repeating anything the guy says without thinking about it on her own, thinks Obamacare is a waste because no one is entitled to government assitance for their health problems, has a vacation home in Costa Rica, has a husband that makes good money, and guess what? She's on disability.....

For Fibromyalgia.

Reading this physically pains me. I think I am owed a check in the mail for reading this post and my subsequent distress.

 

[heyjack70]

There was a good public radio story about this recently. Since the states decreased welfare funding under President Clinton years ago, millions more Americans have been applying for federal disability. Some states have even hired consultants to help them purge their welfare rolls by encouraging people to apply for federal disability. States with crappy welfare benefits are being subsidized by those of us in other states where the state benefits are better.

There is no government push back on disability applications. In other words the government has no lawyers to contest disability applications! So for a persistent applicant, the likelihood their application will be approved is very high. Entire law firms specialize in this area. Whether it's lower back pain or depression a person can very easily get disability if they persist. Hence we see so many people on disablity or applying for it!

So I don't really blame the patients per se. Pursuing disabilty these days is no more a sign of "entitlement" than applying for food stamps or welfare once was. If you're unemployed, and out of money, and your education is substandard, what else can you do? There's a whole culture of Americans who don't seem to "be able to work." If you ask me, if you are a psychiatrist and are deeming victims of the economy to be "borderline" or "antisocial" or "entitled" -- then that is your countertransference and your own political mindset speaking. Ultimately at some level it is the fault of our economy and our school system that people aren't employed, whether it's because we don't train people, we don't have jobs, or we don't simply let people starve if they can't fend for themselves.

I too hate these things, and I feel very bitter about them. But that's just me. The way I approach them currently, is I agree to fill them out. And I say the truth! I say that the patient stands a good chance of recovering if they continue with treatment. I don't care if they get mad. I usually write in "I don't know" to any questions about whether they can work or not and for how long.

I have yet to have a patient come in with a form who actually IS disabled. A severe schizophrenic, say. I don't know what I will do then.

I don't think it's countertransference or political leanings if someone actually has one of these diagnoses, or actually is entitled.

Regarding the second point: A patient with severe schizophrenia will probably have tons of inpatient admissions and outpatient psych records that disability will receive and it will be an open and shut case, so the form will most likely never get to you.
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It's frustrating to me when someone with a reasonably able body and mind is pursuing disability in a deceptive or manipulative way and expects I will be an advocate for that deception. I believe this is a normal response when someone is expecting you to collude with their dishonesty. I think it's wrong to use mild psychiatric diagnoses as justification for somebody not working. If the economy sucks, then we should fix that. We shouldn't try to stretch and cram a diagnosis into something more severe than it is to justify someone not working. The question for disability, in my opinion is, how depressed or anxious do you have to be that you can't put groceries into a bag. Because that's the hurdle in my mind you have to fall beneath to honestly be disabled from mental illness.

To clarify, I'm not talking about severe, chronic mental illnesses like schizophrenia or severe bipolar disorder (though I've seen some of those folks get jobs). I'm focusing this rant on the mildly personality disordered folks with mild to moderate psychosocial stressors that are attempting to get free money and healthcare.

 

[birchswing]

I don't think it's countertransference or political leanings if someone actually has one of these diagnoses, or actually is entitled.

Regarding the second point: A patient with severe schizophrenia will probably have tons of inpatient admissions and outpatient psych records that disability will receive and it will be an open and shut case, so the form will most likely never get to you.
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It's frustrating to me when someone with a reasonably able body and mind is pursuing disability in a deceptive or manipulative way and expects I will be an advocate for that deception. I believe this is a normal response when someone is expecting you to collude with their dishonesty. I think it's wrong to use mild psychiatric diagnoses as justification for somebody not working. If the economy sucks, then we should fix that. We shouldn't try to stretch and cram a diagnosis into something more severe than it is to justify someone not working. The question for disability, in my opinion is, how depressed or anxious do you have to be that you can't put groceries into a bag. Because that's the hurdle in my mind you have to fall beneath to honestly be disabled from mental illness.

To clarify, I'm not talking about severe, chronic mental illnesses like schizophrenia or severe bipolar disorder (though I've seen some of those folks get jobs). I'm focusing this rant on the mildly personality disordered folks with mild to moderate psychosocial stressors that are attempting to get free money and healthcare.

I'm curious about your term "mild psychiatric disorders." I have seen that there can be extremely refractory cases of anxiety, panic, OCD, whereas some people with bipolar or schizophrenia can be very effectively treated with medications. I am sure it can be a burden for someone who has a severe manifestation of anxiety to have society believe it to just be a case of being stressed out, whereas other diagnoses carry a greater "weight." I take psychiatry at its word when it treats these conditions under the medical model. And independently of that I believe that repeat patterns of mental illness are actual actual medical disorders. You also have to consider that patients with long-term psychiatric illnesses have likely been on medications that can contribute to poor physical health and mental faculties, such as long-term benzodiazepine therapy. There are those who make the argument that psychiatric treatment itself could lead to disability. I wouldn't make that argument in any sort of unqualified way, but I do know of examples where treatment, admittedly poor treatment, contributes to a decrease in certain areas of functioning.

 

[heyjack70]

I'm curious about your term "mild psychiatric disorders." I have seen that there can be extremely refractory cases of anxiety, panic, OCD, whereas some people with bipolar or schizophrenia can be very effectively treated with medications. I am sure it can be a burden for someone who has a severe manifestation of anxiety to have society believe it to just be a case of being stressed out, whereas other diagnoses carry a greater "weight." I take psychiatry at its word when it treats these conditions under the medical model. And independently of that I believe that repeat patterns of mental illness are actual actual medical disorders. You also have to consider that patients with long-term psychiatric illnesses have likely been on medications that can contribute to poor physical health and mental faculties, such as long-term benzodiazepine therapy. There are those who make the argument that psychiatric treatment itself could lead to disability. I wouldn't make that argument in any sort of unqualified way, but I do know of examples where treatment, admittedly poor treatment, contributes to a decrease in certain areas of functioning.

What are you meaning with the bolded statement?

In general, based on my experience and training, the anxiety disorders you've mentioned cause less life dysfunction than schizophrenia. This is just my opinion, and I'm sure there are exceptions.

 

[birchswing]

What are you meaning with the bolded statement?

In general, based on my experience and training, the anxiety disorders you've mentioned cause less life dysfunction than schizophrenia. This is just my opinion, and I'm sure there are exceptions.

The bolded statement was my way of trying to say that it seems like people forget that generalized anxiety disorder, for example, is technically considered a medical illness and is real. At times in my life, I have questioned the validity of psychiatric taxonomy. But I think what is more important, and what I have learned through life experience, is that there truly are people who exhibit patterns of behavior at a systems level that inhibit their functioning. I see mental illness like I see functions of variables in math. Or how I see academic theories applied to current events. Mental illness acts on the content of people's lives. People are all unique, with unique lives. And it is those patterns of fear and worry, for example in GAD, that apply themselves to a person's daily life that truly are real. I have seen enough in this area of humanity to know that there are these persistent forces that truly are different between an affected and non-affected individual, regardless of what you call it or whether there is research to show it's caused by x or y. I think sometimes the diagnoses of GAD, again just as an example, can be applied in a way where people forget that the diagnosis is a real thing. It actually means something. Persistent worry and fear are real actors in some people's lives.

I think there are sometimes throw-away diagnoses in medicine. It can be common, for example, for a doctor to say a person has a flu-like virus. IBS is thrown out a lot. I have not sensed this from the field of psychiatry, but I think at a societal level, some of the "garden-variety" diagnoses become viewed and treated the same way. They become diluted.

So, I guess my comment was to say that I believe in the medical model to the extent I believe these are real things. I don't think they are always just circumstantial, situational passing phases of a person's life, and treatment often means something than just getting over it or developing a new attitude, etc, not that you were implying that.

My original post was picking up on the idea of mild psychiatric disorders. I understand there are degrees, and it was my own sensitivity that led to my curiosity. Without going into my personal life, I'll just say what I've said before, which is that I have been surprised that some of the disorders people might consider garden variety can be very refractory and an extreme burden, even though there is no name for them that exceeds what can be viewed as a garden-variety mental illness. And I have also known people with very well controlled schizophrenia who are very successful. In fact, when attending NAMI events in the past, I have found that it was bipolar and schizophrenic patients who spoke the most highly of the changes medications made for them. For them, it seemed to be more of a night-and-day difference than some of the people who seemed to have more lingering, chronic anxiety or depression. Just my experience, and I know there are realities of all mental illnesses I have not seen.

 

[shan564]

It's frustrating to me when someone with a reasonably able body and mind is pursuing disability in a deceptive or manipulative way and expects I will be an advocate for that deception. I believe this is a normal response when someone is expecting you to collude with their dishonesty.

I think that this is the crux of this discussion, with which I'm sure we can all agree. We're approaching it from different angles, but in the end, I'm sure that we'd all be happy to fill out a disability form for somebody who has an honest disabilty. It gets frustrating when they try to either deceive/manipulate us or if they expect us to collude with their dishonesty. If somebody has really severe GAD and is unable to hold down a job, then I'm happy to sign off a disability form for them. But FWIW, the most severe GAD case I've seen recently was a guy who was holding down a job just fine, until he had to quit because sales were down and he wasn't making enough money... I'd be happy to fill out a disability form for him, but he wants to go back to work. The guy with the most severe MDD I've seen recently (probably the most severe I've ever seen) has had a complete turnaround on ECT, and although I'd be happy to fill out a disability form for him, he doesn't want it... he'd rather go back to life as usual. Compare that to people with severe schizophrenia or bipolar, who really need it. Or on the other end of the spectrum, the people who just have post-cocaine dysphoria. Or the malingerers who come in to the ER and say verbatim "I'm hearing voices that tell me to harm myself and to harm others."

 

[countryboy75]

if you are a psychiatrist and are deeming victims of the economy to be "borderline" or "antisocial" or "entitled" -- then that is your countertransference and your own political mindset speaking. Ultimately at some level it is the fault of our economy and our school system that people aren't employed, whether it's because we don't train people, we don't have jobs, or we don't simply let people starve if they can't fend for themselves

Isn't blaming the economy and our school system a form of poticially minded countertransference?

 

[vistaril]

I think we all realize that. For most people, disability is a last-resort refuge).

oh gosh how I wish this were true.

 

[nancysinatra]

if you are a psychiatrist and are deeming victims of the economy to be "borderline" or "antisocial" or "entitled" -- then that is your countertransference and your own political mindset speaking. Ultimately at some level it is the fault of our economy and our school system that people aren't employed, whether it's because we don't train people, we don't have jobs, or we don't simply let people starve if they can't fend for themselves

Isn't blaming the economy and our school system a form of poticially minded countertransference?

I suppose -- it could just be how I see things. But I'm not advocating for putting these people on disability. I agree with the OP -- there are lots of people who actually are borderline or antisocial or just entitled who want disability. But if bringing in a disability form is now considered "diagnostic" for having one of those disorders, it seems like we'd be diagnosing 2/3 of the US population with those disorders before long. At some point the behavior becomes so common it must be called "normal."

My point was just that this is a growing sociological phenomenon, and not a psychiatric condition. I definitely recommend the NPR story which explains it really well.

 

[MacDonaldTriad]

I think this is the NPR story.

http://apps.npr.org/unfit-for-work/

 

[nancysinatra]

I don't think it's countertransference or political leanings if someone actually has one of these diagnoses, or actually is entitled.

Regarding the second point: A patient with severe schizophrenia will probably have tons of inpatient admissions and outpatient psych records that disability will receive and it will be an open and shut case, so the form will most likely never get to you.
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It's frustrating to me when someone with a reasonably able body and mind is pursuing disability in a deceptive or manipulative way and expects I will be an advocate for that deception. I believe this is a normal response when someone is expecting you to collude with their dishonesty. I think it's wrong to use mild psychiatric diagnoses as justification for somebody not working. If the economy sucks, then we should fix that. We shouldn't try to stretch and cram a diagnosis into something more severe than it is to justify someone not working. The question for disability, in my opinion is, how depressed or anxious do you have to be that you can't put groceries into a bag. Because that's the hurdle in my mind you have to fall beneath to honestly be disabled from mental illness.

To clarify, I'm not talking about severe, chronic mental illnesses like schizophrenia or severe bipolar disorder (though I've seen some of those folks get jobs). I'm focusing this rant on the mildly personality disordered folks with mild to moderate psychosocial stressors that are attempting to get free money and healthcare.

I think you are missing my point. I actually agree with you about everything. Of course a subset of disability applicants are entitled or antisocial. And I find it offensive when people come in with anxiety or depression and want me to say that they can't bag groceries. They're asking the wrong person.

And with due respect to forensic psychiatrists, what holy grail of knowledge to they possess that makes their evaluations more reliable than guesswork done by anyone else? I'm sure there are situations where forensic knowledge can answer fitness for duty questions, but come on, total inability to work??? It's interesting to me that our society would deem anyone "incapable of working," unless they are comatose or dead. Go back to Dickensian England or wherever and see how much "disability funds" they handed out. Even dead people in some cases make money -- witness Vladimir Lenin. I just don't get where we ever got the idea that inability to work is something health related. It's economy related. The vast majority of people in this world could work, if the right job appeared.

My attitude is, unless a patient has no arms and no legs I cannot make the statement that they can or cannot do manual work like bag groceries or drive a paddleboat. Unless they are on a ventilator for life I am not qualified to say that they can or cannot do deskwork. Everything else is gray area and I won't get into that. It's not what I was trained to do. So that is how I get out of it.

My personal opinion is -- if people want to work, they'll find a way. I have a patient with severe agoraphobia, and he gets out to a job. He endures the panic attacks. I would have thought he couldn't work, but lo and behold he does. Not everything in human behavior can be codified in the DSM -- there's also things like financial necessity and work ethic. Those play a role in whether someone will find work, and I'm really not trained to evaluate them.

 

[shan564]

My personal opinion is -- if people want to work, they'll find a way. I have a patient with severe agoraphobia, and he gets out to a job. He endures the panic attacks. I would have thought he couldn't work, but lo and behold he does. Not everything in human behavior can be codified in the DSM -- there's also things like financial necessity and work ethic. Those play a role in whether someone will find work, and I'm really not trained to evaluate them.

+1. With the exception of severe schizophrenia and bipolar I, most patients can work. That's not to say that I think they should - I've personally urged patients with severe MDD or GAD to pursue disability - but they can. I'm happy to put my medical opinion onto a disability form as long as the patient is being honest. But I'm not going to lie for them. And substance-induced depression is not a disability.

 

[birchswing]

I think you are missing my point. I actually agree with you about everything. Of course a subset of disability applicants are entitled or antisocial. And I find it offensive when people come in with anxiety or depression and want me to say that they can't bag groceries. They're asking the wrong person.

And with due respect to forensic psychiatrists, what holy grail of knowledge to they possess that makes their evaluations more reliable than guesswork done by anyone else? I'm sure there are situations where forensic knowledge can answer fitness for duty questions, but come on, total inability to work??? It's interesting to me that our society would deem anyone "incapable of working," unless they are comatose or dead. Go back to Dickensian England or wherever and see how much "disability funds" they handed out. Even dead people in some cases make money -- witness Vladimir Lenin. I just don't get where we ever got the idea that inability to work is something health related. It's economy related. The vast majority of people in this world could work, if the right job appeared.

My attitude is, unless a patient has no arms and no legs I cannot make the statement that they can or cannot do manual work like bag groceries or drive a paddleboat. Unless they are on a ventilator for life I am not qualified to say that they can or cannot do deskwork. Everything else is gray area and I won't get into that. It's not what I was trained to do. So that is how I get out of it.

My personal opinion is -- if people want to work, they'll find a way. I have a patient with severe agoraphobia, and he gets out to a job. He endures the panic attacks. I would have thought he couldn't work, but lo and behold he does. Not everything in human behavior can be codified in the DSM -- there's also things like financial necessity and work ethic. Those play a role in whether someone will find work, and I'm really not trained to evaluate them.

How do you reconcile these two statements? You're saying you are insulted when people with an anxiety disorder ask for you to fill out a form documenting how their medical illness impacts their lives, and yet you simultaneously are shocked that a person with an anxiety disorder can work.

 

[Therapist4Chnge]

My niche is TBI and there can be a ton of grey area in the work, so I pick and choose the cases I see bc I do not want to contribute to someone trying to defraud the gov't so they can sit at home and watch Jerry Springer and drink a 12-pk. There are plenty of people with far worse problems are working 2-3 jobs trying to earn an honest living, and a portion of them probably should be on disability but aren't. It is frustrating to see legitimate cases I've followed since the initial dx/injury get mucked up bc the system is flooded by borderline to completely baseless claims from people trying to get something for nothing. The Worker's Comp slip & fall claims are tied with fake PTSD as the most infuriating cases I see trying to qualify for fully disabled. There are legit cases for each, but they are a fraction of what actually is trying to push through the system.

 

[billypilgrim37]

While this doesn't speak so much to disability, and this is a model for behavior in children, I think I will defer to Ross Greene:

http://www.livesinthebalance.org/kids-do-well-if-they-can

I don't know how people in mental health make it through the day without this philosophy. Otherwise there is just too much to be angry about.

 

[heyjack70]

While this doesn't speak so much to disability, and this is a model for behavior in children, I think I will defer to Ross Greene:

http://www.livesinthebalance.org/kids-do-well-if-they-can

I don't know how people in mental health make it through the day without this philosophy. Otherwise there is just too much to be angry about.

The idea is certainly something to consider. Would you apply it to all behavior though? If the bank robber could have obeyed the law, he wouldn't have robbed the bank. It removes personal responsibility. I think the reality is murkier than either extreme.

 

[billypilgrim37]

The idea is certainly something to consider. Would you apply it to all behavior though? If the bank robber could have obeyed the law, he wouldn't have robbed the bank. It removes personal responsibility. I think the reality is murkier than either extreme.

We're psychiatrists, not philosophers. There's not much of "personal responsibility" in our job. I'm not saying we can't have those feelings, and I'm not saying it shouldn't inform our work (especially w/ regards to something like a disability application). But worrying about "personal responsibility" doesn't do anything to help get you through the day as a psychiatrist. It just makes you angry and upset.

I think it does apply to the bank robber. If the bank robber had the "skills" (broadly defined here--emotional regulation, inherent motivation, resiliency, distress tolerance, ability to control impulsivity, education, et al.) to do something better than rob a bank, he would have. Are there flaws to this logic? Sure. Again, we're psychiatrists, not philosophers. Our job is to get through the day in good enough shape to do it again tomorrow.

With my CBT patients, I'm often asking a) is something true, and then b) is it helpful? My "borderline" (her outpt dx) who is fixated on her husband's infidelity and giving her herpes and his refusal to reconcile with her about it despite them still being married, a) it is true that you were treated terribly and it's true that you deserve for him to apologize, to explain all the why's, etc., but b) it's not helpful to keep pushing this because it got you to the point of a suicide attempt.

In the same way, a) it is true that a lot of folks should take more personal responsibility, but b) worrying about that doesn't do a damn thing to help me help the person in front of me. As I said before, I don't do the disability paperwork at all, so I'm not saying people don't have personal responsibility and that it is always the taxpayer's responsibility to make up for that.

What I'm saying is that going on disability, malingering in the hospital, drug-seeking, all the behaviors that make us want to quit our jobs, these are not success stories. Nobody (well, almost nobody--there are always those kids whose environment has polluted them so bad that they really don't know better, but that almost reinforces my point) dreams of these things when they're writing the "What I want to do when I grow up" story in third grade. They wanted to do better. But they didn't. They didn't because they couldn't. By definition. Because no one would choose these things if they had a legitimately better option. Bagging groceries and flipping burgers and licking envelopes are not fulfilling tasks that most would prefer to sitting at home on disability. Some people clearly do, and we appreciate that about them. We appreciate them because they have something in common with us, as we're working our asses off.

This isn't to say that philosophically I don't agree with pretty much everything everybody else says on here about this topic. Like, I don't think Nancy's rant above is inaccurate. I would just say that personal responsibility and motivations to do better should be seen as skills. If these folks had those skills, they would do something better the vast majority of the time.

At the heart of it, I guess I'm just saying this is an attitude that helps me tolerate some of the inherent bull**** associated with our job. It helps me work a little more effectively with the really bad kids, the really bad families, the drug-seekers, the borderlines, the fibromyalgiacs, malingerers, the narcissists, and all the other labels we slap on people we don't like. It's true enough to be helpful.

Then I can save the personal responsibility rants for bourbon-swilling sessions on the weekends.

 

[gibits]

Just answer the questions honestly. That's all you can do. If they get mad then tell them they can see someone else. I also remind them that SSI payments are tiny and that even minimum wage pays better. Idk about the rest of the country but most pts I have only get $800 a month. Even a cheap broad and care cost $500 a month. Why would you settle for that when even the lowest paying job can provide more? I always try to put that in perpective, especially if I feel they won't qualify.

On the other hand, for people that really need it, SSI just isn't enough. I can't even imagine living off just $1000 a month much less $800. I never feel guilty about filling out the paperwork.

 

[Therapist4Chnge]

Just answer the questions honestly. That's all you can do. If they get mad then tell them they can see someone else. I also remind them that SSI payments are tiny and that even minimum wage pays better. Idk about the rest of the country but most pts I have only get $800 a month. Even a cheap broad and care cost $500 a month. Why would you settle for that when even the lowest paying job can provide more? I always try to put that in perpective, especially if I feel they won't qualify.

It's never just that money. Add in subsidized housing, food stamps, under the table income, $ from or for dependents/family, etc. As for taking disability instead of working....it is something for nothing. Watching Judge Joe Brown + gaming >>> waking up early, getting nagged by your boss, and dealing with angry customers.

 

[michaelrack]

I think it does apply to the bank robber. If the bank robber had the "skills" (broadly defined here--emotional regulation, inherent motivation, resiliency, distress tolerance, ability to control impulsivity, education, et al.) to do something better than rob a bank, he would have. .

I don't think this philosophy applies to all bank robbers/criminal behavior. If a bank robber had higher education, impulse control, etc he might be a model citizen-or he might be incredibly destructive (eg Madoff, or pick your favorite villain from the financial crisis)

 

[billypilgrim37]

I don't think this philosophy applies to all bank robbers/criminal behavior. If a bank robber had higher education, impulse control, etc he might be a model citizen-or he might be incredibly destructive (eg Madoff, or pick your favorite villain from the financial crisis)

Right, but that's being concrete. What do these douches lack that they wind up this way? Inability to tolerate narcissistic injury? Because what is corporate structure except for a series of narcissistic injuries?

It's still something. I'm not saying these things because they are true in an all encompassing sense. I'm saying them because they are helpful for getting through the day as a psychiatrist. It doesn't have to effect how you vote or how you behave in a jury or what you expect out of your friends and family.

 

[michaelrack]

Right, but that's being concrete. What do these douches lack that they wind up this way? Inability to tolerate narcissistic injury? Because what is corporate structure except for a series of narcissistic injuries?

It's still something. I'm not saying these things because they are true in an all encompassing sense. I'm saying them because they are helpful for getting through the day as a psychiatrist. It doesn't have to effect how you vote or how you behave in a jury or what you expect out of your friends and family.

You are right, inability to tolerate nacissistic injury can be a factor in many cases. I think lack of conscience is also a factor. I am not trying be concrete. I am a believer in individual responsibility and the power of evil- although I do recognize and agree that psychological factors have a large influence. This is how I view the world at large, and not how I conceptualize my psychiatric patients. I do agree that the philosophy you have linked to is reasonable framework for a psychiatrist to operate in while performing his professional duties.

 

[birchswing]

Some of you may be interested in the talks Olof Palme gave in the 1970s on disability. He compared the US system to the Swedish system (he was the prime minister of Sweden until his assassination). He said that in Sweden, people with disabilities are viewed as being in a different life stage than others, whereas in the US people with a disability are viewed as a different species. He said there is a realization that we will all be in life stages, such as infancy and old age, where we cannot work. He believed it was worth any cost to enable a person to work. The often quoted argument he made was that if it cost the government $40,000 to enable a person to work at a job where he earned $40,000, it was a net benefit to society to have him integrated into the system. You help a person with a disability to work the same way you help a child learn to walk.

I have found that there is a survival of the fittest mentality in the US. After a person with a disability leaves high school, there are only accommodations to a disability--there is no law that a person should be helped in necessary ways to have a place in society. Even at the university level, survival of the fittest often applies. I hear people sometimes say that it should be that way because what would that person do once they "got in the real world."

I always respond that there is no place that is not the real world. School is the real world as much as having a job is. Sweden is the real world. And we can make our world any way we want to.

It is difficult for people who receive disability to get a job and to not live in poverty. From what I have heard, a person who receives disability can have no more than $2,000 to their name at any one time. As much money as they earn is subtracted from their payments (which can be much lower than what was quoted--in my case I have known them to be $400). Once you have secured a job and earn a certain amount, you are cut off, which also then cuts off access to Medicaid. There are ticket-to-work programs that ease these slightly but they apply to SSDI and not SSI.

You can read about the difference here:
http://ssa-custhelp.ssa.gov/app/ans...social-security-disability-and-ssi-disability

I've had jobs in the US where if you aren't able to work 60 hours a week, they have no use for you. And I know from the perspective of people who are employed it's hard to understand why an employer would want overtime for employees, but in these cases, it was because the jobs were from home in which you are contracted, meaning practically no labor laws apply.

I lived in Sweden for one year as a child, where they practiced inclusion in the classroom (probably what we would call radical inclusion). And I think what people don't realize, and it's a very sad thing not to realize, is that people are hurting themselves by cutting themselves off to all the people of the world. It's not for the person with the disability that inclusion should be practiced. It is for everyone.

The analogy would be as if we still had an attitude that racial integration was only for the benefit of black people.

I come at this from the perspective that our current system needs to be completely reimagined. But as the current system stands, I think disability payments can be a very necessary source of survival.

If you asked a disabled person what they were good at doing and approached it from the perspective of matching his skills to a value that could be provided to society, I think almost every person could be employable. But when a person with a severe disability, especially one that is more marked by stigma and is harder to understand, like a psychiatric disability, and there is this expectation of normalcy, I think it's hard for that person to find a peghole he fits into.

And which is there more help for: receiving disability or getting a job? (If it wasn't obvious, my opinion is that it's the first.) And the other question is why they have to be mutually exclusive. A person who receives disability exclusively and then gets a job but loses his health insurance is probably going to have difficulty staying at that job.