Do you help your patient's apply for SSI who have a Personality Disorder?

[shahseh22]

I'm seeing a guy who has been to jail multiple times and has clear features of Antisocial PD (I haven't formally diagnosed him). He has a hard time getting along with others and loses multiple jobs. He is demanding I help him with SSI paperwork and I have clearly told him, that is unlikely to be accepted. But I was just curious for patients with Borderline PD or any other PD as main diagnosis), do you guys fill out paperwork and list it as the main diagnosis?

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[Attending1985]

No I don’t

 

[AD04]

I tell my patients they are welcome to their notes, but I don't fill out disability paperwork. I encourage patients to work.

If I were you, I would practice getting more comfortable saying no if I don't want to do something -- especially for demanding antisocial patients.

 

[nexus73]

I would do this for borderline personality disorder for sure. Many BPD patients are extremely disabled and will never be able to maintain a job (although I try to stay optimistic). I'd think schizoid and schizotypal would be candidates too, though don't see them as much in clinic. I'd have to think about antisocial.

 

[birchswing]

I could be wrong, but is that how any of that works?

I thought you just filed with SSA, and SSA sends out requests to doctors for medical records.

I went through this, and I cannot recall asking any doctor to help me or fill anything out. SSA just collected raw data and sends it off to DDS. Maybe there was some extra step, but not that I recall.

Once you get a request from SSA for medical records, I don't think there is an option if you want to do it or not. I believe you are legally required at that point to turn over extant records except for psychotherapy notes.

 

[Sushirolls]

Nope is the answer.

But birch has the general idea. Social Security disability is a benefit that people apply for and in the process, the Social Security Administration (SSA) requests records for their own adjudication process. The forms requesting records will have dates on them. Pay attention to those dates and that they match up for when patient was treated - if at all.

One of the questions on these forms is do you want to be available to be the evaluator for the patient.
Another of the questions is an open ended do you have anything you want to add about this disability request.

I have added extra for patients with schizophrenia, but oddly enough I learned later even that patient was denied on first request for disability.

In summary, SS disability requests are easy - you do nothing - except send records.

The more complex question is Short Term Disability and Long Term Disability for an employed individual and all the paperwork connected to the insurance company that manages these claims/benefit requests....

 

[TexasPhysician]

No

 

[erg923]

I'm seeing a guy who has been to jail multiple times and has clear features of Antisocial PD (I haven't formally diagnosed him). He has a hard time getting along with others and loses multiple jobs. He is demanding I help him with SSI paperwork and I have clearly told him, that is unlikely to be accepted. But I was just curious for patients with Borderline PD or any other PD as main diagnosis), do you guys fill out paperwork and list it as the main diagnosis?

Do you think the government should pay someone to be an dingus and ignore the social contact of civilized society?! If you don't agree that he should have disability for these behaviors, then dont do it.

 

[birchswing]

Do you think the government should pay someone to be an dingus and ignore the social contact of civilized society?! If you don't agree that he should have disability, then dont do it.

That's not how any of it works. Treating physicians/psychologists don't decide if someone gets SSI.

The government does create an artificial private marketplace for physicians, psychologists, etc., however, driving up wages, which is kind of cushy. (If you don't believe that's true, then all the hand-wringing about NPs lowering wages can't also be true as it's another artificial marketplace and the creation of it is just a taste of what it would look like if there were a completely open market.) I can't think of any country where doctors are remunerated as well. Not only does the government allow and create an artificial marketplace, the medical boards authorized by the government at the state level and at the national level (FSMB) take government funding and grants from HHS for all sorts of practices outside of their original scope of licensing.

SSI is not a cushy life or one that anyone aspires to. Fraud is low. The bar is high. The payments are well below the poverty rate. In the 1980s there was a mythology created around the welfare queen. It was just that, a myth.

 

[erg923]

That's not how any of it works. Treating physicians/psychologists don't decide if someone gets SSI.

The government does create an artificial private marketplace for physicians, psychologists, etc., however, driving up wages, which is kind of cushy. (If you don't believe that's true, then all the hand-wringing about NPs lowering wages can't also be true as it's another artificial marketplace.) I can't think of any country where doctors are remunerated as well. Not only does the government allow and create an artificial marketplace, the medical boards authorized by the government at the state level and at the national level (FSMB) take government funding and grants from HHS for all sorts of practices outside of their original scope of licensing.

SSI is not a cushy life or one that anyone aspires to. Fraud is low. The bar is high. The payments are well below the poverty rate. In the 1980s there was a mythology created around the welfare queen. It was just that, a myth.

If I don't think its needed, I'm not gonna waste anyone's times engaging in the process. Well within my right to decline to do this if I think it is countertherapeutic.

 

[birchswing]

If I don't think its needed, I'm not gonna waste anyone's times engaging in the process. Well within my right to decline to do this if I think it is countertherapeutic.

If SSA sends you a request, I'm pretty sure you have to send records back.

Not sure what happens if you don't. But I don't think it's optional.

Edit: Checked with someone who knows. They can do subpoenas but apparently this almost never happens.

 

[Ironspy]

I'm seeing a guy who has been to jail multiple times and has clear features of Antisocial PD (I haven't formally diagnosed him). He has a hard time getting along with others and loses multiple jobs. He is demanding I help him with SSI paperwork and I have clearly told him, that is unlikely to be accepted. But I was just curious for patients with Borderline PD or any other PD as main diagnosis), do you guys fill out paperwork and list it as the main diagnosis?

No. Borderline PD is treatable and most recover. I send records if requested for ssi and do short term disability letters for patients as needed for IOP/PHP level of care

 

[clausewitz2]

John Gunderson (RIP) made 'work before love', i.e., no serious romantic relationships if you're not working on a regular basis, a key cornerstone of GPM.

Otto Kernberg says people doing TFP need to be regularly engaged with work or volunteering for a substantial chunk of their week, every week, or he will suspend treatment until they are.

Marsha Linehan, I suspect, would question what behaviors you are reinforcing for someone with BPD when you sign off on the idea that they are the kind of person who is actually unable to work.

Why on earth would you ever support long-term disability for someone whose major issue is BPD??

 

[birchswing]

John Gunderson (RIP) made 'work before love', i.e., no serious romantic relationships if you're not working on a regular basis, a key cornerstone of GPM.

Otto Kernberg says people doing TFP need to be regularly engaged with work or volunteering for a substantial chunk of their week, every week, or he will suspend treatment until they are.

Marsha Linehan, I suspect, would question what behaviors you are reinforcing for someone with BPD when you sign off on the idea that they are the kind of person who is actually unable to work.

Why on earth would you ever support long-term disability for someone whose major issue is BPD??

If you look at one of the largest proponents and architects of a welfare state, Olof Palme, the idea was never actually that people with disabilities would not work. I am just paraphrasing here, but he said something to the effect that if it cost $40,000 to put a man in a job where he earned $40,000 a year, it was worth it. He viewed disability as a developmental stage, like birth or old age, and thought that like infants or old people are elevated to have roles in society, people with disabilities should be too at any cost.

SSI is extremely problematic in that it does make working when you want to very difficult. It is a trap. And it gets linked to Medicaid, as well, which people lose as they transition out of SSI (although Medicaid expansion helped with that to some degree in some states). No one with a disability though is going to start working and find a job that has insurance (which you still have to pay your share of) that will replace Medicaid.

It's probably a cliche to say it, but UBI and universal healthcare would solve a lot of these issues. just reforming SSI would help so that it doesn't de-incentivize work (people often assume ticket to work programs are part of SSI--they are not).

 

[erg923]

If SSA sends you a request, I'm pretty sure you have to send records back.

Not sure what happens if you don't. But I don't think it's optional.

No. I dont think so.

 

[WisNeuro]

No. I dont think so.

If a records request is sent with patient signed ROI, you are obligated to send that info. You can technically bill for time required if your state statutes allow it, but refusal to send records in an appropriate time frame constitutes an ethics violation.

You are not required to fill out paperwork, but you are required to send records when requested appropriately.

Edit: Additionally, most states have statutes related to patient's rights about their records. Yes, in some extenuating circumstances, you can withhold records in some cases where harm is expected. But, these extenuating circumstances are a high bar to clear and I can almost assure you that withholding them in the case of request for SSI/SSDI services will not be looked upon favorably by your state board when you get a complaint. Nor would the state likely look favorably on it if you were also sued/charged for violating state law.

 

[Candidate2017]

I'm seeing a guy who has been to jail multiple times and has clear features of Antisocial PD (I haven't formally diagnosed him). He has a hard time getting along with others and loses multiple jobs.

This guy is head and shoulders above the jail/prison population based on the fact he actually has had a job. And multiple jobs, no less. You should tell him that.

 

[erg923]

If a records request is sent with patient signed ROI, you are obligated to send that info. You can technically bill for time required if your state statutes allow it, but refusal to send records in an appropriate time frame constitutes an ethics violation.

You are not required to fill out paperwork, but you are required to send records when requested appropriately.

Edit: Additionally, most states have statutes related to patient's rights about their records. Yes, in some extenuating circumstances, you can withhold records in some cases where harm is expected. But, these extenuating circumstances are a high bar to clear and I can almost assure you that withholding them in the case of request for SSI/SSDI services will not be looked upon favorably by your state board when you get a complaint. Nor would the state likely look favorably on it if you were also sued/charged for violating state law.

I think we are talking about different things here.

I would not fill out any disability paperwork or questionnaires sent to me/given to me for a patient like what was described by OP. SSA cant tell me I have to give fill out their paperwork for a patient's disability claim. I thought that's what we were talking about? I would sent my tx notes/records to whoever or for whatever as long as their was an appropriate ROI in place.

 

[birchswing]

I think we are talking about different things here.

I would not fill out any disability paperwork or questionnaires sent to me/given to me for a patient like what was described by OP. SSA cant tell me I have to give fill out their paperwork for a patient's disability claim. I thought that's what we were talking about? I would sent my tx notes/records to whoever or for whatever as long as their was an appropriate ROI in place.

That's why i didn't really understand the OP's question.

AFAIK, there is no form for a patient to hand a doctor and say, "Sign off on SSI."

SSA (federal) works with DDS (state) who have their own doctors who evaluate medical evidence. The evidence is supposed to speak for itself.

If SSI were just given out by treating doctors, everyone would be approved or there would be cottage industries of doctors who rubber-stamped claims. DDS has quotas and has to go exactly by a book to find a matching set of impairments. They know how their bread is buttered, meaning they don't just go handing out SSI (or SSDI for that mater) to anybody.

There are also MEs (medical experts) outside of DDS, but those are also not treating physicians. They are randomly assigned to cases. They have VEs, as well (vocational experts) who testify as to whether a person could do a job--and they can get very specific, down to whether someone could do something like basket-weaving (probably not a current example, but something like that). If the VE says yes, the claim could be denied (assuming such a job is available).

Not nearly as easy as people think to get into these systems, and the systems are not as cushy as people think either.

Average payments for SSI are I think around $400 something per month. It's not something anyone can live off of.

 

[erg923]

That's why i didn't really understand the OP's question.

AFAIK, there is no form for a patient to hand a doctor and say, "Sign off on SSI."

SSA (federal) works with DDS (state) who have their own doctors who evaluate medical evidence. The evidence is supposed to speak for itself.

If SSI were just given out by treating doctors, everyone would be approved or there would be cottage industries of doctors who rubber-stamped claims. DDS has quotas and has to go exactly by a book to find a matching set of impairments. They know how their bread is buttered, meaning they don't just go handing out SSI (or SSDI for that mater) to anybody.

There are also MEs (medical experts) outside of DDS, but those are also not treating physicians. They are randomly assigned to cases. They have VEs, as well (vocational experts) who testify as to whether a person could do a job--and they can get very specific, down to whether someone could do something like basket-weaving (probably not a current example, but something like that). If the VE says yes, the claim could be denied (assuming such a job is available).

Not nearly as easy as people think to get into these systems, and the systems are not as cushy as people think either.

Average payments for SSI are I think around $400 something per month. It's not something anyone can live off of.

OP said patient was trying to get him to do/help with some paperwork for SSI disability. I am sure OP is not lying. I would not “do any paperwork” for this patient's disability claim. As said before, I would send my notes if requested due to ethical obligation, but I would do absolutely nothing else to support or further the claim, as the idea of disability for anti-social behavior/ASPD is beyond ridiculous.

 

[birchswing]

OP said patient was trying to get him to do/help with some paperwork for SSI disability. I am sure OP is not lying. I would not “do any paperwork” for this patient's disability claim. As said before, I would send my notes if requested due to ethical obligation, but I would do absolutely nothing else to support or further the claim, as the idea of disability for anti-social behavior/ASPD is beyond ridiculous.

The OP isn't lying, but if he/she looked at the paperwork, the very first page of the application says do not ask your healthcare provider for help with this form, so I am not sure why it's an issue. I went through this process and had zero interaction with any of my doctors regarding it.

If they need help filling out the form, they might be in need of a social worker more than anything. Not sure.

https://www.ssa.gov/forms/ssa-3368-bk.pdf

IF YOU NEED HELP
You can get help from other people, such as a friend or family member. Please do not ask your healthcare provider to complete this report. If you cannot complete the report, a Social Security Representative will assist you. If you have an appointment, please have the completed report ready when we contact you. If we ask you to do so, please mail the completed report to us ahead of time.

YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS THAT YOU DO NOT ALREADY HAVE. With your permission, we will request your records. The information that you give us on this report tells us where to request your medical and other records.

 

[dl2dp2]

Gonna chime in and voice a dissent. What's the difference between "treatment resistant depression" and "personality disorder?"

Personally I don't really think withholding SSI from a person like this is really doing anyone any favors, either him, or taxpayers. It's preferably for this person to having $ to buy some cigarettes than harassing old ladies in the streets.

 

[clausewitz2]

Gonna chime in and voice a dissent. What's the difference between "treatment resistant depression" and "personality disorder?"

Personally I don't really think withholding SSI from a person like this is really doing anyone any favors, either him, or taxpayers. It's preferably for this person to having $ to buy some cigarettes than harassing old ladies in the streets.

There often isn't a huge difference. I also don't think giving SSI to people with dysthymia is doing them any favors either. In many cases it is actively harmful. I get your pragmatic argument but you risk blowing up any chance at better functioning for the long-term for the person in question. Especially a problem with BPD where 80% or so of people go into remission over the course of a decade.

 

[birchswing]

I agree SSI can be harmful, but not because it gives people money which is meager.

SSI is like a drug with bad side effects. It's a poverty program that forces poverty as a vocation.

It's like a deal with the devil. It's a net, and a very complicated one.

If it were like UBI with no strings attached, I think you would see a lot more healthy behaviors.

 

[dl2dp2]

There often isn't a huge difference. I also don't think giving SSI to people with dysthymia is doing them any favors either. In many cases it is actively harmful. I get your pragmatic argument but you risk blowing up any chance at better functioning for the long-term for the person in question. Especially a problem with BPD where 80% or so of people go into remission over the course of a decade.

Let's say the person doesn't get SSI, but instead gets supported parasitically from his parents. Is this a better scenario? (or worse, being homeless and hungry) I have yet to see this being therapeutic?

I don't find it plausible that $800 a month really prevents people from working if they really wanted to. People getting paid $100 a day at the minimum age. If they don't want to work what harm does it do exactly?

Why is personality disorder (or chronic depression) specifically excluded from consideration for a medical condition that causes disability? Is it because it's purely subjective and can cause malingering? But the same can be said about acute depression or schizophrenia, or things like CFS/chronic lyme, etc. This logically makes no sense to me.

 

[birchswing]

Let's say the person doesn't get SSI, but instead gets supported parasitically from his parents. Is this a better scenario? (or worse, being homeless and hungry) I have yet to see this being therapeutic?

I don't find it plausible that $800 a month really prevents people from working if they really wanted to. People getting paid $100 a day at the minimum age. If they don't want to work what harm does it do exactly?

Why is personality disorder (or chronic depression) specifically excluded from consideration for a medical condition that causes disability? Is it because it's purely subjective and can cause malingering? But the same can be said about acute depression or schizophrenia, or things like CFS/chronic lyme, etc. This logically makes no sense to me.

(I can't speak to the diagnoses and whether people should get SSI.)

It's $800 if you're lucky. Average payment is in 500s--it was 400s before. I just looked it up now. I used to get it and it was 400 something. Depends on many variables.

There is a dangerous chasm between being on SSI and working and taking care of yourself (of course no one truly takes care of themselves, but in the colloquial sense of that phrase).

It's not so much the payments that bind you. If your wages grow at all, you do lose SSI payments bit by bit (anything over $65 in income starts counting against you). What is worse is you can never have more than $2,000 in assets to your name. So you can never save. You can never make plans. You can't accept help from family and friends. At least not without a lawyer and setting up some sort of trust.

And then if you want to trial work to see if it's possible, you risk losing everything. I mean you could fail at work and reapply for SSI. But a risk many would probably rather not take, given that getting on SSI is so hard to begin with. (Ticket to Work is not applicable to SSI.)

And more than losing the 400 a month or whatever it is you get in SSI, you risk losing food stamps and Medicaid, which are far more valuable than the actual SSI payments. There are ways to keep Medicaid if you start working and varies state to state, but it is complicated and the chances of getting an SSA representative that understands the rules approaches 0%. Medicaid expansion has probably helped with that if you live in a state that has that.

Again, I'm not against the payments.

UBI as a supplement would make so much more sense. The problem with SSI in general is that it is a program for people in poverty that forces them in a myriad of ways to stay in poverty. I'm not just saying that philosophically. You literally have to be in poverty to stay in the program. No more than $2,000 to your name and income over $65 starts reducing payments.

 

[dl2dp2]

Again, I'm not against the payments.

None of what you say makes me think that SSI disincentivizes people who can work to work and "pretend that they are disabled", and use SSI either as a primary or a secondary gain.

 

[clausewitz2]

Let's say the person doesn't get SSI, but instead gets supported parasitically from his parents. Is this a better scenario? (or worse, being homeless and hungry) I have yet to see this being therapeutic?

I don't find it plausible that $800 a month really prevents people from working if they really wanted to. People getting paid $100 a day at the minimum age. If they don't want to work what harm does it do exactly?

Think about the robustness of the evidence for the utility of behavioral activation in alleviating depression. You are absolutely right that people who really want to work are not going to be prevented from working by $800 dollars per month. The vast majority of people applying for disability are not doing it because they have access to careers they are passionate about or anything like that. It remains harmful for them to be given entree into a system where they are actively penalized for working when it is in fact the case that they are not lacking capacity to work.

A persistently-depressed person will say that they just feel they are simply unable to get out of bed. Tell them that you have just set fire to their house, and wait to see how long it takes them to revise that opinion. "Here is a check as long as you don't undertake significant gainful employment and go through a whole process swearing up and down that you are utterly incapable of meaningful employment" is not likely to motivate change.

Why is personality disorder (or chronic depression) specifically excluded from consideration for a medical condition that causes disability? Is it because it's purely subjective and can cause malingering? But the same can be said about acute depression or schizophrenia, or things like CFS/chronic lyme, etc. This logically makes no sense to me.

Acute depression and decompensated schizophrenia are different. Also, in most cases, they are transient - hence the acute. The vast majority of people with a psychotic disorder diagnosis are capable of working. some of them might need accommodations, sure. Let's put our energy into pushing for those. If you don't feel comfortable or up to the task of figuring out the conditions that would allow them to work, why do you feel like you are able to judge whether or not they can work in general?

I don't think CFS or chronic lyme should warrant disability either in the vast majority of cases, for what it's worth.

If you want to take the cynic's line of "who cares if they can actually work, sign the form, they get a check, everybody wins", this is all irrelevant. If you think signing a paper saying someone can't work should involve your honest and correct belief that they in fact literally cannot work, arrived at through some defensible means, this matters.

 

[erg923]

I am getting confused. This is not a philosophical debate. I guess it could be. But its not at this point.

OP says patient essentially has a pattern of being a dick and having poor social skills. No other psychiatric disorders are known to be present. "Disability" (by any metric...commercial insurance or SSA) is about enumerating functional impairments that are directly attributed to a psychiatric illness that has not responded to treatment. Does anyone really consider the criteria of ASPD alone to be "psychiatric illness???"

Maybe we work with this individual to increase social awareness behavior, do empathy induction, and work on pro-social behavior? If this fails. I don't know what else clinical psychiatry, per se, really has to do with it? There are limits to what medical professionals can and should do here. We don't run a special social justice agency last time i checked.

 

[birchswing]

"who cares if they can actually work, sign the form, they get a check, everybody wins", this is all irrelevant. If you think signing a paper saying someone can't work should involve your honest and correct belief that they in fact literally cannot work, arrived at through some defensible means, this matters.

Again, just for clarity, unless I'm in some parallel universe, this is all irrelevant because there is no paper to sign, unless you're working for DDS or are an SSA ME.

 

[clausewitz2]

Again, just for clarity, unless I'm in some parallel universe, this is all irrelevant because there is no paper to sign, unless you're working for DDS or are an SSA ME.

SSA definitely doesn't just take my word for it that someone is disabled. There are, however, lots of other long-term disability paperwork that I get handed on which I am asked to proffer my opinion as to whether or not someone can work again or go back to their old job where what I put down actually does matter quite a lot.

There are different ideas of disability at play but the basic questions remain the same.

 

[Old&InTheWay]

Does anyone realy consider the criteria of ASPD alone to be psychiatric illness??

I think this really depends on why a person is exhibiting the behaviors that define antisocial personality disorder. While perhaps reliable for research purposes, the construct of ASPD is not valid in any meaningful way; the criteria can be met by individuals with psychopathy, borderline personality disorder, ADHD, ASD, TBI, among others.

It's also interesting that "failure to sustain work" is one of the criteria for ASPD. So if this diagnosis itself actually meant something to someone, encouraging a patient to work would be one step towards the cure.

 

[erg923]

I think this really depends on why a person is exhibiting the behaviors that define antisocial personality disorder. While perhaps reliable for research purposes, the construct of ASPD is not valid in any meaningful way; the criteria can be met by individuals with psychopathy, borderline personality disorder, ADHD, ASD, TBI, among others.

It's also interesting that "failure to sustain work" is one of the criteria for ASPD. So if this diagnosis itself actually meant something to someone, encouraging a patient to work would be one step towards the cure.

Qualifying for disability is about specific "functional impairment"...and why that is sustained despite documented efforts/engagement in medical/psychiatric treatment.

 

[Old&InTheWay]

Qualifying for disability is about specific "functional impairment"...and why that is sustained despite sustained efforts/engagement in medical/psychiatric treatment,

Yeah that makes sense; I was answering your specific question that I quoted. To expand on how that relates to disability, I wouldn't give an ASPD diagnosis any weight in my determination of whether a person ought to qualify for disability, because it essentially says nothing about the nature of their disability (or whether they have one at all).

 

[clausewitz2]

Qualifying for disability is about specific "functional impairment"...and why that is sustained despite sustained efforts/engagement in medical/psychiatric treatment

On the other hand, easy to justify that someone has reached maximal medical improvement with a condition that has essentially no well-validated treatments...

 

[erg923]

On the other hand, easy to justify that someone has reached maximal medical improvement with a condition that has essentially no well-validated treatments...

The pychiatricisizing of anti-social/psychopathic behavior is....bad JuJu for the field.

Probably invented by the Q-anons? 🙂

 

[birchswing]

The pychiatricisizing of anti-social/psychopathic behavior is....bad JuJu for the field.

Probably invented by the Q-anons? 🙂

How do you make a distinction between someone with ASPD having agency over hurting others and someone with depression having agency over self-loathing and lethargy? Aren't they both hurting people (this is more philosophical as I know very little about ASPD)?

I'll refer to the great Murder by Death:
(Jamesir Bensonmum) "She murdered herself in her sleep, sir."
(Dick Charleston) "You mean suicide?"
(Jamesir Bensonmum) "Oh no, it was murder, all right. Mrs. Twain HATED herself."

 

[erg923]

How do you make a distinction between someone with ASPD having agency over hurting others and someone with depression having agency over self-loathing and lethargy?

I'll refer to the great Murder by Death:
(Jamesir Bensonmum) "She murdered herself in her sleep, sir."
(Dick Charleston) "You mean suicide?"
(Jamesir Bensonmum) "Oh no, it was murder, all right. Mrs. Twain HATED herself."

By talking to them and doing a comprehensive and/or structured psychiatric evaluation/interview with collateral informants.....like we have all been trained to do.

Kinda like Dr. Emil Skoda from Law and Order. But doing much, much more than he does. 🙂

 

[Old&InTheWay]

On the other hand, easy to justify that someone has reached maximal medical improvement with a condition that has essentially no well-validated treatments...

Garbage in, garbage out. Good luck finding a validated treatment for an invalid construct.

 

[erg923]

Garbage in, garbage out. Good luck finding a validated treatment for an invalid construct.

I know Psychiatry doesn't like to admit this, but we mostly treat symptoms....not "psychiatric disorders." I really don't think this can even be debated at this point.

If you want to "treat" lack of empathy and habitual criminality.....I think we are looking in the wrong place. Or so I think. And so does the demonstrable evidence up until this point?

 

[erg923]

I can't understand why a well person would want to go to an American prison multiple times.

Lol. really??? I would explore this assumption further.

Again, maybe we don't intellectualize too much here? People who hurt people because they want to hurt people? Bad. People who hurt people as a side effect of their illness? Bad. But maybe not assss bad.... Right?

Everyone is deserving of empathy. This can/should be done and delivered in controlled environment if they are dangerous.

 

[K9friend]

I am not a psychiatrist, but as a pharmacist and patient with mental illness, nothing has been more vital to my recovery than working. I'm not currently diagnosed with bpd or any personality disorder, but I do have bipolar disorder and a psychotic disorder. When i was on disability, it didn't further my recovery - I rarely got out of bed and lived in horrible conditions because I never showered or cleaned. Sure, it was hard to get out of bed before I was on disability - but once my claim was approved, there was zero incentive to keep pushing myself to try.

I do think disability can be helpful in the short term to allow for a progressive return to full time work because the transition is extremely challenging emotionally and cognitively. Being on disability can also open up employment support services that wouldn't otherwise be available. I can also see a need for long term disability in patients with truly severe impairments. However, in my (non-expert) opinion, patients who truly cannot engage in competitive employment would still benefit strongly from regular engagement in volunteer work. I just don't see how anything good can come of never leaving your home or even getting out of bed. I think the pandemic has shown us how vital regular social interactions and predictable routines are to our well-being. I do have negative symptoms with my psychotic illness, and they make it extremely hard to care for myself - but disability takes away any incentive to even try.

I genuinely don't intend to minimize the struggles of people with mental illness. However, those struggles don't mean we should put more people on long-term disability - they mean that our society should be willing to provide intensive hands-on employment support so that people can succeed despite their illness. Long term disability doesn't solve the problem of severe mental illness; it just transfers it to the shoulders of the government. I'm not a policy expert, but I think government-sponsored financial incentives to hire people with disabilities benefit everyone. The employer gets compensated for any extra support they need to provide, the person with a disability earns more money than they would have on SSI/SSDI and reaps the many mental health benefits of working, and the government can collect taxes from the patient since they are working.

TL;DR - I am nowhere near an expert, but personal experience has shown me that there's nothing more healing than work. Rather than expanding SSI/SSDI, we should put the money toward employment support services that make it possible for everyone to contribute to society.

 

[Attending1985]

I am not a psychiatrist, but as a pharmacist and patient with mental illness, nothing has been more vital to my recovery than working. I'm not currently diagnosed with bpd or any personality disorder, but I do have bipolar disorder and a psychotic disorder. When i was on disability, it didn't further my recovery - I rarely got out of bed and lived in horrible conditions because I never showered or cleaned. Sure, it was hard to get out of bed before I was on disability - but once my claim was approved, there was zero incentive to keep pushing myself to try.

I do think disability can be helpful in the short term to allow for a progressive return to full time work because the transition is extremely challenging emotionally and cognitively. Being on disability can also open up employment support services that wouldn't otherwise be available. I can also see a need for long term disability in patients with truly severe impairments. However, in my (non-expert) opinion, patients who truly cannot engage in competitive employment would still benefit strongly from regular engagement in volunteer work. I just don't see how anything good can come of never leaving your home or even getting out of bed. I think the pandemic has shown us how vital regular social interactions and predictable routines are to our well-being. I do have negative symptoms with my psychotic illness, and they make it extremely hard to care for myself - but disability takes away any incentive to even try.

I genuinely don't intend to minimize the struggles of people with mental illness. However, those struggles don't mean we should put more people on long-term disability - they mean that our society should be willing to provide intensive hands-on employment support so that people can succeed despite their illness. Long term disability doesn't solve the problem of severe mental illness; it just transfers it to the shoulders of the government. I'm not a policy expert, but I think government-sponsored financial incentives to hire people with disabilities benefit everyone. The employer gets compensated for any extra support they need to provide, the person with a disability earns more money than they would have on SSI/SSDI and reaps the many mental health benefits of working, and the government can collect taxes from the patient since they are working.

TL;DR - I am nowhere near an expert, but personal experience has shown me that there's nothing more healing than work. Rather than expanding SSI/SSDI, we should put the money toward employment support services that make it possible for everyone to contribute to society.

Thanks for sharing your story. It’s very admirable you went from SSDi to a pharmacy degree. I’m sure the full story is very interesting and worth sharing as well.
I can’t agree with you more on how our current disability system is harmful to those with mental illness. We need more in our field and patients like you advocating for changes like the ones you mentioned.

 

[dl2dp2]

Think about the robustness of the evidence for the utility of behavioral activation in alleviating depression. You are absolutely right that people who really want to work are not going to be prevented from working by $800 dollars per month. The vast majority of people applying for disability are not doing it because they have access to careers they are passionate about or anything like that. It remains harmful for them to be given entree into a system where they are actively penalized for working when it is in fact the case that they are not lacking capacity to work.

A persistently-depressed person will say that they just feel they are simply unable to get out of bed. Tell them that you have just set fire to their house, and wait to see how long it takes them to revise that opinion. "Here is a check as long as you don't undertake significant gainful employment and go through a whole process swearing up and down that you are utterly incapable of meaningful employment" is not likely to motivate change.

If you want to take the cynic's line of "who cares if they can actually work, sign the form, they get a check, everybody wins", this is all irrelevant. If you think signing a paper saying someone can't work should involve your honest and correct belief that they in fact literally cannot work, arrived at through some defensible means, this matters.

You are not asking the right questions. You are posing hypotheses that are not tested.

There's strong evidence that once people enter into SSI, they do not seek employment or refuse employment. However, it's questionable whether the SSI entry is the CAUSE of ongoing lack of employment. This is a major confound. There is no study that shows that persistently depressed people function better before than after obtaining SSI in any other domain.

Given that entitlement programs are by design to provide a very minimum standard of living regardless of whether someone is "motivated to work", I don't find it convincing to argue that one should put up barriers if people really really want it.


There's an analogous situation in substance use disorders, where traditionally housing benefits most prominently is contingent on motivation to achieve abstinence. When they did many RCTs that compared non contingent housing to contingent housing, they found that people who were assigned non contingent housing actually did BETTER in eventually achieving abstinence. This became the rationale beyond policies like HousingFirst. I wouldn't be surprised if randomized a bunch of antisocial people to either $X per month vs. waiting list, the group on the waiting list do worse in 12 months. In any case this study is not done, except in contexts like drug use, which shows evidence contrary to your intuition.

 

[Attending1985]

You are not asking the right questions. You are posing hypotheses that are not tested.

There's strong evidence that once people enter into SSI, they do not seek employment or refuse employment. However, it's questionable whether the SSI entry is the CAUSE of ongoing lack of employment. This is a major confound. There is no study that shows that persistently depressed people function better before than after obtaining SSI in any other domain.

Given that entitlement programs are by design to provide a very minimum standard of living regardless of whether someone is "motivated to work", I don't find it convincing to argue that one should put up barriers if people really really want it.


There's an analogous situation in substance use disorders, where traditionally housing benefits most prominently is contingent on motivation to achieve abstinence. When they did many RCTs that compared non contingent housing to contingent housing, they found that people who were assigned non contingent housing actually did BETTER in eventually achieving abstinence. This became the rationale beyond policies like HousingFirst. I wouldn't be surprised if randomized a bunch of antisocial people to either $X per month vs. waiting list, the group on the waiting list do worse in 12 months. In any case this study is not done, except in contexts like drug use, which shows evidence contrary to your intuition.

Not wanting to work isn’t a disability. What you’re essentially promoting is universal income. I won’t argue the benefits of that. The difference is SSDI is saying here is some money because you’re “unable” to work. There are psychological consequences of that which aren’t helpful to a recovery based model which is what all mental health services should be.

 

[clausewitz2]

You are not asking the right questions. You are posing hypotheses that are not tested.

There's strong evidence that once people enter into SSI, they do not seek employment or refuse employment. However, it's questionable whether the SSI entry is the CAUSE of ongoing lack of employment. This is a major confound. There is no study that shows that persistently depressed people function better before than after obtaining SSI in any other domain.

Given that entitlement programs are by design to provide a very minimum standard of living regardless of whether someone is "motivated to work", I don't find it convincing to argue that one should put up barriers if people really really want it.


There's an analogous situation in substance use disorders, where traditionally housing benefits most prominently is contingent on motivation to achieve abstinence. When they did many RCTs that compared non contingent housing to contingent housing, they found that people who were assigned non contingent housing actually did BETTER in eventually achieving abstinence. This became the rationale beyond policies like HousingFirst. I wouldn't be surprised if randomized a bunch of antisocial people to either $X per month vs. waiting list, the group on the waiting list do worse in 12 months. In any case this study is not done, except in contexts like drug use, which shows evidence contrary to your intuition.

I have no problem with housing first. The critical part that makes this an inappropriate analogy to disability is that housing first is not contingent. If these RCTs evicted people who stopped using for a prolonged period of time, then they would be comparable.

Non-contingent aid does not incentivize any particular behavior, because it is not contingent, not because it is aid. You want to talk about a UBI, sure, i can get behind that. But the disability system is a terrible means for achieving that sub rosa.


All of the studies we do have looking at disability on particular that look at return to work based on a number of disorders suggest that those disorders tend to get worse or not improve when someone is assigned to stay home v return to work. the foundational model of FEP programs involves aggressive attempts to support people in maintaining employment or education because even people with psychosis end up doing a lot better if they can stay working or in school. Personality disorders especially are disorders where social functioning is what is most impaired, and bpd in particular is notable for problems with sustaining a sense of personal identity. You plan to make that better by giving someone a check that goes away when they become more functional in society and when they acquire an identity beyond 'unemployed person'? Really?

I am on board with harm reduction but not harm enhancement.

Edit: you're also wrong about the design of entitlement programs in general. Disability in particular is designed to insure some minimum standard of living for people who are explicitly incapable of meaningful work. Motivation is irrelevant only in the sense that if you are capable and unmotivated the disability system says 'too bad'. At the end of the day the question is one of capacity, not desire.

 

[clausewitz2]

I am not a psychiatrist, but as a pharmacist and patient with mental illness, nothing has been more vital to my recovery than working. I'm not currently diagnosed with bpd or any personality disorder, but I do have bipolar disorder and a psychotic disorder. When i was on disability, it didn't further my recovery - I rarely got out of bed and lived in horrible conditions because I never showered or cleaned. Sure, it was hard to get out of bed before I was on disability - but once my claim was approved, there was zero incentive to keep pushing myself to try.

I do think disability can be helpful in the short term to allow for a progressive return to full time work because the transition is extremely challenging emotionally and cognitively. Being on disability can also open up employment support services that wouldn't otherwise be available. I can also see a need for long term disability in patients with truly severe impairments. However, in my (non-expert) opinion, patients who truly cannot engage in competitive employment would still benefit strongly from regular engagement in volunteer work. I just don't see how anything good can come of never leaving your home or even getting out of bed. I think the pandemic has shown us how vital regular social interactions and predictable routines are to our well-being. I do have negative symptoms with my psychotic illness, and they make it extremely hard to care for myself - but disability takes away any incentive to even try.

I genuinely don't intend to minimize the struggles of people with mental illness. However, those struggles don't mean we should put more people on long-term disability - they mean that our society should be willing to provide intensive hands-on employment support so that people can succeed despite their illness. Long term disability doesn't solve the problem of severe mental illness; it just transfers it to the shoulders of the government. I'm not a policy expert, but I think government-sponsored financial incentives to hire people with disabilities benefit everyone. The employer gets compensated for any extra support they need to provide, the person with a disability earns more money than they would have on SSI/SSDI and reaps the many mental health benefits of working, and the government can collect taxes from the patient since they are working.

TL;DR - I am nowhere near an expert, but personal experience has shown me that there's nothing more healing than work. Rather than expanding SSI/SSDI, we should put the money toward employment support services that make it possible for everyone to contribute to society.

Yes, thank you so much for sharing your experience. In my ideal world we would have way more extensive employment support services that are available to anyone who has any significant challenge to maintaining employment. I also totally support short term graded return to work for someone who has been out of a job for a while under the umbrella of accomodations to make it possible for everyone to work to the best of their ability. For all the reasons you lay out, fundamentally the correct response to someone struggling to hold a job is 'how do we make working easier for you' instead of 'you don't have to try any more'.

 

[dl2dp2]

Not wanting to work isn’t a disability. What you’re essentially promoting is universal income. I won’t argue the benefits of that. The difference is SSDI is saying here is some money because you’re “unable” to work. There are psychological consequences of that which aren’t helpful to a recovery based model which is what all mental health services should be.

Not exactly. HousingFirst is not a universal housing program. It's saying that if you are homeless you get assigned housing. Homeless people are "unable" to find housing. It doesn't mean that I show up to the shelter and demand to be assigned to housing I'll get it.

All of the studies we do have looking at disability on particular that look at return to work based on a number of disorders suggest that those disorders tend to get worse or not improve when someone is assigned to stay home v return to work.

Yes, but we went over the confounding issue. People who return to work do better because they are slated to do better at baseline. You need to RANDOMIZE whether someone gets SSI vs. not. To my knowledge, no such study has been done as it's been thought unethical. If you can truly articulate that creating some kind of artificial barrier for people who have a diagnosis of personality disorder to get SSI as a TREATMENT, I'm sure someone would be willing to fund that study. But you can't, because it's fairly clear that there's no equipoise.

I am not against aggressive supportive employment for people who are on SSI. NOT AT ALL. I'm 100% for it. These are two independent issues. Whether you recommend someone get supportive employment AFTER you get SSI vs. whether you refuse to fill application paper for people who want to be on SSI.... this should be plain.

 

[OldLeech]

I am getting confused. This is not a philosophical debate. I guess it could be. But its not at this point.

OP says patient essentially has a pattern of being a dick and having poor social skills. No other psychiatric disorders are known to be present. "Disability" (by any metric...commercial insurance or SSA) is about enumerating functional impairments that are directly attributed to a psychiatric illness that has not responded to treatment. Does anyone really consider the criteria of ASPD alone to be "psychiatric illness???"

Maybe we work with this individual to increase social awareness behavior, do empathy induction, and work on pro-social behavior? If this fails. I don't know what else clinical psychiatry, per se, really has to do with it? There are limits to what medical professionals can and should do here. We don't run a special social justice agency last time i checked.

I am a retired psychiatrist from the Czech Republic. I joined a year ago thinking I might help out and just keep up to date. But I ended up just observing.

I just wanted to point out that ASPD is one of the most well-researched psychiatric disorders. No psychiatric disorder has a silver bullet etiology, but with ASPD there is almost certainly a genetic component, and we see it start manifesting in childhood. It is tragic for the person it affects and their family.

It is not "being a dick." That's how it feels to you as someone who treats people with the disorder, but it is not what it is.

If you see it only that way, the early interventions that could be helpful will not be used.

I can't speak to the American welfare model, but of course ASPD affects employability—not only for the person with the disorder but for their coworkers.

If the condition was not treated with early intervention and has resulted in multiple incarcerations, there are going to be employability issues.

Fortunately, ASPD does improve somewhat over the lifespan generally on its own, but usually not in the prime years of a typical person's career.

 

[VA Hopeful Dr]

Yes, thank you so much for sharing your experience. In my ideal world we would have way more extensive employment support services that are available to anyone who has any significant challenge to maintaining employment. I also totally support short term graded return to work for someone who has been out of a job for a while under the umbrella of accomodations to make it possible for everyone to work to the best of their ability. For all the reasons you lay out, fundamentally the correct response to someone struggling to hold a job is 'how do we make working easier for you' instead of 'you don't have to try any more'.

That's been part of my problem with SS disability. Practically speaking, its life long. This would be a whole other discussion if there was a short/medium term disability option. Help with expenses while you get treatment to be able to go back to work.