Mental illness and disability benefits: What do you think is appropriate?

[futureapppsy2]

I'm curious what you all think are appropriate/inappropriate situations for someone to receive disability payments due to mental illness. I've seen a lot of (well-founded, I think) criticism that these systems can act as disincentives for those with treatable conditions to not pursue or put full effort into treatment as well as concerns that they can be iatrogenic by basically promoting behavioral inactivation (in MDD, for example). Otoh, a huge reason that people struggle to maintain work are the soft skills of employment (e.g., showing up on time and consistently, managing conflict, acting appropriately with co-workers, bosses, customers, etc), and mental illness can obviously really impact those skills. even if someone can technically do the tasks of the job

Thoughts?

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[Sanman]

I try to avoid having a stance on this as there is what I would like to see and the dumpster fire that is ssdi in the U.S. Having a family member on workers comp and then SSDI for a physical workplace injury, I have found the system wholly lacking in any kind of understanding of how real world injury should be treated.

 

[thebalmofhurtminds]

This may be tangential, but part of my issue answering this question is that it's so difficult to find a middle ground because of our healthcare and employment situation in this country. So many of my chronic pain patients would do well with a quarter or part-time job with accommodations at least to start, but that practically tends to mean losing affordable health insurance, unstable hours, and terrible working environments. It's exhausting to even think about, so having an opinion isn't really a priority for me.

 

[erg923]

I'm curious what you all think are appropriate/inappropriate situations for someone to receive disability payments due to mental illness. I've seen a lot of (well-founded, I think) criticism that these systems can act as disincentives for those with treatable conditions to not pursue or put full effort into treatment as well as concerns that they can be iatrogenic by basically promoting behavioral inactivation (in MDD, for example). Otoh, a huge reason that people struggle to maintain work are the soft skills of employment (e.g., showing up on time and consistently, managing conflict, acting appropriately with co-workers, bosses, customers, etc), and mental illness can obviously really impact those skills. even if someone can technically do the tasks of the job

Thoughts?

I used to do alot of disability file review for several major commercial insurers (Sun Life Financial. CIGNA, MetLife, Lincoln Financial, UNUM, etc). The bar is very high there. The bar is also high for Social Security. The struggle I saw most from physicians and members when doing this was educating that its not about diagnosis/diagnoses at all. Its about functional impairment in daily life. And alot of the time, depending on the definition used and how strictly one wants to apply it....it's about the literal INABILITY to work. It takes alot to document that, and most PCP or psychiatrist attendings don't know nothin about that and will simply write/attest that patient shouldn't work because of their illness. That's not how it works. The question posed to an examiner in that situation is (usually) not " But would they be a good/conscientious employee"....for example.

Many, many factors go into these determinations. Degree of functional impairment, Hill's model of causation, causality in general, definitions of "disabled", etc, It's hard to make any kind of sweeping statement.

I would really hope that all mental health professionals agree that people should spend their time getting pleasure and mastery via what most us call....work/a job. There are a myriad of reasons for this (and I'm not going to write a lit review for everyone). Some are obvious of course, and some are bit more based on statistical outcomes and mental health/quality of life and financial metrics.

Also, let's not loose sight of the fact that "work" is called work for a reason. Its not all suppose to be easy or fun. That's pat of what makes it healthy.

 

[PsyDr]

Maybe this could best be answered by reading the introductory texts on the matter. This would clear up most of the definitions, and misconceptions.

Hint: individuals with severe mental illness and ID work full time jobs.

 

[Therapist4Chnge]

The point about healthcare being tied to employment is definitely a hurdle, especially when so many Americans do not qualify as part-time employees (and if they are, it's $$$). I think a lot of the "disability" could be more manageable if the insurance piece was figured out. As for what qualifies, it's a mess. People (and providers) are often confused about "can't work job X" v. "can't work ANY job"; the latter is the standard. I avoid those evals like the plague.

 

[PsyDr]

The point about healthcare being tied to employment is definitely a hurdle, especially when so many Americans do not qualify as part-time employees (and if they are, it's $$$). I think a lot of the "disability" could be more manageable if the insurance piece was figured out. As for what qualifies, it's a mess. People (and providers) are often confused about "can't work job X" v. "can't work ANY job"; the latter is the standard. I avoid those evals like the plague.

No, it’s not. The former is related to an own occupation disability policy; the latter is an “any occupation disability policy”.

 

[Therapist4Chnge]

I'm glad I don't do them.

 

[erg923]

Maybe this could best be answered by reading the introductory texts on the matter. This would clear up most of the definitions, and misconceptions.

Hint: individuals with severe mental illness and ID work full time jobs.

Much like when assessing "medical necessity criteria," there is room for judgment and bias (good or bad) when making these determinations.

But, generally, it doesn't matter how one "feels" about the concept of disability. That's not relevant in only but some academic sense which will never be solved by "talking bout it." That why we have predetermined definitions and subscribed roles when we are interpreting and working with them.

 

[WisNeuro]

Much like when assessing "medical necessity criteria," there is room for judgment and bias (good or bad) when making these determinations.

But, generally, it doesn't matter how one "feels" about the concept of disability. That's not relevant in only but some academic sense which will never be solved by "talking bout it." That why we have predetermined definitions and subscribed roles when we are interpreting and working with them.

I agree that if we are operating in this area, we need to be following appropriate statutes. But, to what I think some of the intent of the original question, I do believe that we as a field are in a position at helping to shape the policy around these statutes. We should definitely be studying this in terms of maximizing QoL and day-to-day functioning that is grounded in empirical means, rather than policy being determined by legislatures which all too often have a grade school level of scientific literacy.

 

[futureapppsy2]

I agree that if we are operating in this area, we need to be following appropriate statutes. But, to what I think some of the intent of the original question, I do believe that we as a field are in a position at helping to shape the policy around these statutes. We should definitely be studying this in terms of maximizing QoL and day-to-day functioning that is grounded in empirical means, rather than policy being determined by legislatures which all too often have a grade school level of scientific literacy.

Yes, I'm more interested for the purposes of this thread in what people THINK the standard should be and why and less so how it plays out in practice.

 

[erg923]

I agree that if we are operating in this area, we need to be following appropriate statutes. But, to what I think some of the intent of the original question, I do believe that we as a field are in a position at helping to shape the policy around these statutes. We should definitely be studying this in terms of maximizing QoL and day-to-day functioning that is grounded in empirical means, rather than policy being determined by legislatures which all too often have a grade school level of scientific literacy.

I think that is fine. I do not think psychological science has come evidence that would attest upon the harms of work for John Q ID or schoziophrenic...generally speaking though.

 

[WisNeuro]

I think that is fine. I do not think psychological science has come evidence that would attest upon the harms of work for John Q ID or schoziophrenic...generally speaking.

Of course not, but work is a fairly wide-ranging notion. These aren't binary variables, and we probably shouldn't treat them as such.

 

[futureapppsy2]

Hint: individuals with severe mental illness and ID work full time jobs.

Some do, but many don't. Can some that don't work probably work with the right combination of work environment, support, and treatment? Yes. Can some only realistically work very part-time? Yes. Can some likely not work in any current existent set-up? Probably.

We point to programs and interventions that have success getting people with SPMI, etc., back to work, but often the bar for what constitutes a good outcome is relatively low. During my postdoc (in psychiatric rehab), some of the faculty submitted a manuscript with an SPMI sample with employment rates of ~50%. They were criticized by reviewers because that number seemed "unrealistically high."

 

[erg923]

Of course not, but work is a fairly wide-ranging notion. These aren't binary variables, and we probably shouldn't treat them as such.

If I say that Brittany Spears should be freed and that Bam Margera should be jailed in a smelly home for the goofy for being a dummy.....would I be shunned here?

Just wondering...

 

[PsyDr]

Some do, but many don't. Can some that don't work probably work with the right combination of work environment, support, and treatment? Yes. Can some only realistically work very part-time? Yes. Can some likely not work in any current existent set-up? Probably.

We point to programs and interventions that have success getting people with SPMI, etc., back to work, but often the bar for what constitutes a good outcome is relatively low. During my postdoc (in psychiatric rehab), some of the faculty submitted a manuscript with an SPMI sample with employment rates of ~50%. They were criticized by reviewers because that number seemed "unrealistically high."

There are about 6 different core concepts to disability here, that you are missing.

 

[bluecolourskies]

This is what a professor told me (having to prove an inability to hold down a job and that treatments have failed). So a person has to “fail” at getting a job over and over (get fired/quit) basically, to show that they cannot hold a job

 

[futureapppsy2]

The point about healthcare being tied to employment is definitely a hurdle, especially when so many Americans do not qualify as part-time employees (and if they are, it's $$$). I think a lot of the "disability" could be more manageable if the insurance piece was figured out. As for what qualifies, it's a mess. People (and providers) are often confused about "can't work job X" v. "can't work ANY job"; the latter is the standard. I avoid those evals like the plague.

I think there's also the practical--though not policy--distinction of "can ACTUALLY get and keep a job" versus "can THEORETICALLY get and keep a job." We're increasingly seeing this come into play as more and more autistic people age into adulthood and manage to get college degrees (though that can also be a challenge) but can't actually get and keep a job, because of the social communication skills inherent in doing that.

 

[R. Matey]

1. I think some of it is related to the relatively poor categories we have to classify mental health conditions in the first place. Disability for "depression" or "anxiety" can mean different vastly different collections of symptoms and degree of severity. I've seen those whom have literally tried everything (CBT, TMS, ketamine, antidepressants, ECT, etc.) and still struggle with disabling depression. The DSM does us zero favors in treating these folks as the same. They're not. I've also seen: "Well, my [cousin, brother, nephew, neighbor, ex-girlfriend's child's husband] got on disability for depression and I don't think I can work. Some people want disability because they can't work at their current job. Others have low work related self-efficacy. I've seen a lot of FMLA granted due to stressful work environments where there has been very little therapy involving stress management or the patient won't engage. All of this is called "depression." I imagine there's a similar degree of variability between "can't" and "won't" when it comes to disability due to other psychiatric conditions.

2. The VA folks have probably seen it more than I have, but my experience with PTSD is that if one is on disability for PTSD, they do not want treatment for their PTSD. Psychotherapy almost always becomes sabotaged by treatment interfering behavior because a person perceives a threat to their livelihood. In one state I worked, Medicaid benefits came the attached string of maintaining involvement with "mental health," which functionally resulting in either a lot of treatment interfering behavior when an bone fide treatment for PTSD was administered including provider change requests or getting better from the treatment and continuing to mark that one had the diagnosis on the requisite forms to continue to receive payment. In a minority of cases, people returned to work and were happy with their treatment. We sing of them.

3. I also think that money is a power reinforcer, not just for patients, but also for their lawyers. There is 100% an industry surrounding obtaining SSDI benefits of all stripes, but I've known of some law firms that specialize in mental health disability. My guess is that some are more scrupulous than others in terms of cases they accept. And whatever we gate-keep as a profession may be subject to interpretation by a lawyer or shoved off to an unsuspecting mid-level or an arrogant psychiatrist seeking to appease their patient by writing a letter or filling out some forms.

4. Work is a very important part of life. Work gives us community, a sense of purpose, and contributes to subjective well-being in addition to providing us with resources needed to survive. This forum is a good example of that. My hypothesis is that removing work from someone's life will be detrimental to their mental health with the only exception being the most severe cases. I agree with others that we don't do enough in this country to provide support for individuals who could probably work part-time or would benefit from some supported employment intervention. The science isn't there because these kinds of interventions are expensive to design, implement, study, and maintain over the long haul and nobody wants to pay for it.

 

[clausewitz2]

I think there's also the practical--though not policy--distinction of "can ACTUALLY get and keep a job" versus "can THEORETICALLY get and keep a job." We're increasingly seeing this come into play as more and more autistic people age into adulthood and manage to get college degrees (though that can also be a challenge) but can't actually get and keep a job, because of the social communication skills inherent in doing that.

I work with a young autistic man who was intelligent and functional enough to get an engineering degree and has a resume apparently impressive enough to get hired to at least four entry-level engineering jobs but has not held any of them for more than a month or so for exactly this reason. There is a rapid accumulation of misunderstandings, inadvertent offense, and miscommunications that apparently lead his employers to believe it is not worth trying to remediate his performance. The fact that it is so rapid makes me think it is not an issue of technical incompetence; presumably they would try to train that a bit first before relaunching the whole hiring process (though I admit I am not privy to their deliberations).

He did a lot better working the meat counter at a grocery store (when he didn't have to interact with customers or many other co-workers) but it seems like there in an ideal world be some way of exploiting his abilities and talents more fully than this.

 

[PsyDr]

I think there's also the practical--though not policy--distinction of "can ACTUALLY get and keep a job" versus "can THEORETICALLY get and keep a job." We're increasingly seeing this come into play as more and more autistic people age into adulthood and manage to get college degrees (though that can also be a challenge) but can't actually get and keep a job, because of the social communication skills inherent in doing that.

That's theoretical, NOT practical. The issue is WHICH job. We are all inclined towards some job, but that's not necessarily the job or pay that we want.

In the case of a social communication deficit. Will that impair a sales job? Probably. Will that impair a pure programmer job, a math PhD job, or pathologist job? Probably not. Or it hasn't for those very real individuals that I know.

It gets more complicated, because the issue of reasonable accommodations comes into play. The employer's ability to provide the accommodations is individually defined. I've been to a restaurant that exclusively employ individuals with deafness and another one that employs individuals with intellectual disabilities. That's not something that most restaurants can accommodate, but it shows that individuals with those struggles have the ability to work. Which is why the WHO changed the concept of disability to a model of "participant restriction", which is sort of defined as impairment stemming from diagnosis, and how that impairment interacts with the specific environment.

The Deaf community is really a model for this.

 

[MCParent]

That's theoretical, NOT practical. The issue is WHICH job. We are all inclined towards some job, but that's not necessarily the job or pay that we want.

Exactly. Not being to get a job in the area you were trained in, want to do, pays well, etc. =/= disabled.

 

[futureapppsy2]

That's theoretical, NOT practical. The issue is WHICH job. We are all inclined towards some job, but that's not necessarily the job or pay that we want.

In the case of a social communication deficit. Will that impair a sales job? Probably. Will that impair a pure programmer job, a math PhD job, or pathologist job? Probably not. Or it hasn't for those very real individuals that I know.

It gets more complicated, because the issue of reasonable accommodations comes into play. The employer's ability to provide the accommodations is individually defined. I've been to a restaurant that exclusively employ individuals with deafness and another one that employs individuals with intellectual disabilities. That's not something that most restaurants can accommodate, but it shows that individuals with those struggles have the ability to work. Which is why the WHO changed the concept of disability to a model of "participant restriction", which is sort of defined as impairment stemming from diagnosis, and how that impairment interacts with the specific environment.

The Deaf community is really a model for this.

If social communication skills weren't important for those jobs, then we would probably see much higher rates of employment among autistic adults. They may be more tolerant of "weird" behavior, but you still have to play the social "game" to some degree. Engineers are definitely fired for being incredibly hard to work with, STEM faculty get denied tenure because they won't/can't play the social games of academia, etc,

Yes, people can do well in environments that specifically support them (especially if it's above the legal bar of "reasonable"), but that's not a practical solution for everyone or most people who would need those types of accommodations. I have an autistic colleague who is a successful professor (non-TT), but it works in large part because they were brought on and mentored by someone who is really, really, really committed to accessibility and inclusion. Would most jobs work if you said that you could never attend a morning meeting or participate in any group phone calls? Probably not. Similarly. Deaf individuals may work wonderfully at the few restaurants out there that are Deaf-owned and operated--it's going to be much more of a struggle anywhere else (and in fact, we see this with Deaf community clusters in, say, DC). Someone theoretically being able to do well in a specific niche job with an extremely accepting environment is great, but that doesn't necessarily replicate on a large scale.

Similarly, if you have someone with treatment non-responsive depression who misses half the days, gets a quarter amount of the work done while they are there, and frequently mentions suicidal ideation to coworkers, it's going to be hard to find an employer who will be willing to handle that. Heck, it's hard enough to get something relatively simple like speech-to-text software as an accommodation.

 

[borne_before]

That's theoretical, NOT practical. The issue is WHICH job. We are all inclined towards some job, but that's not necessarily the job or pay that we want.

I think you're touching on disability often being about an interaction between the individual's deviation from normal and environment. Take the bright young autistic engineer who can't get past his first month. However, if there was a company that was more understanding or hired a coach, or put the autistic engineer in the basement to work, his disability might go away.

Take myself for an example, I have ADHD and dysgraphia. I did really bad in school until I went to college and could type everything and structure my life in a such a manner to minimize my challenges. That's why I struggle with this stuff, because context matters and I don't think there will ever be a one size fits all approach.

But working as a psychologist who specializes in neurodevelopmental disorders has me worried about a few things regarding disability:

(1) The welfare state incentivizes more people to leach off the system (I get more if I have x diagnoses). I think it's a pretty well understood fact that when Clinton changed welfare policies and unemployment, the same people just went out and got disability benefits instead of developing their skills.

(2) The covid era has been a great example of showing that many people would rather sit on their asses for 600 dollars a week and consume over contribute. There are tons of job shortages for jobs that are not as financially reinforcing or rewarding. I get it though.

(3) It drives me crazy because most of the people that I've work with who have a mild to moderate ID love their "jobs" or volunteer positions and would work more if they couldn't lose their benefits.

(4) Disability is kind of like porn... You know it when you see it.

(5) Work and not having a safety net is important for growth. I've got a brother who was at a real risk of becoming a neckbeard/neet. My parents even bought him a trailer to live in when he was 20. However, when my parents started pulling their financial support away after he dropped out college, that brother got a job, lost 100 pounds, and became a cop (his dream). Although "uncomfortable," having the "safety net" pulled out from the brother really helped him develop and grow. He could have easily went the other way, into disability land when he injured his back for not tazering someone. Now he's a court investigator and has two great kids and a wonderful wife. That same brother also had his colon removed and poops in a bag. But, he's out there contributing.

(6) People have every right to mess their lives up and not be the best they could be. But, I think that's more an induvial issue than a societal one.

 

[biomom]

I work with a young autistic man who was intelligent and functional enough to get an engineering degree and has a resume apparently impressive enough to get hired to at least four entry-level engineering jobs but has not held any of them for more than a month or so for exactly this reason. There is a rapid accumulation of misunderstandings, inadvertent offense, and miscommunications that apparently lead his employers to believe it is not worth trying to remediate his performance. The fact that it is so rapid makes me think it is not an issue of technical incompetence; presumably they would try to train that a bit first before relaunching the whole hiring process (though I admit I am not privy to their deliberations).

He did a lot better working the meat counter at a grocery store (when he didn't have to interact with customers or many other co-workers) but it seems like there in an ideal world be some way of exploiting his abilities and talents more fully than this.

This is my 26 year old son. Works in a warehouse now and does great. They are very accommodating of him.

 

[PsyDr]

....Similarly, if you have someone with treatment non-responsive depression who misses half the days, gets a quarter amount of the work done while they are there, and frequently mentions suicidal ideation to coworkers...

You are talking about a bunch of different things. The issue is what is the individual unable to do? Mentioning suicide is NOT about function. Cognitive slowing that results in reduced work productivity IS about functional. The latter may have an effect on disability, but not the former. These are introductory text level things.

 

[Ollie123]

Interesting question. As with most things, I think there are many shades of grey here and the devil is in the details on a lot of it. I also think it depends on the context, like PsyDr alludes to above. Right or wrong, someone with a specific own-occupation disability insurance plan should have significantly more wiggle room to qualify than the prototypical SSDI case that comes to mind first for most people.

While not an easy answer, this is definitely one of those topics where - were I supreme overlord of all things - I would call the whole system a failure, scrap it and start anew. I won't rehash what has already been said, but our legal, healthcare, insurance, political and other systems are all a hot mess. Any "fix" I can think of is going to also create new problems because the whole thing is jacked up.

I think its undeniable some mental health issues are disabling. Picture true catatonia. Picture severe schizophrenia unresponsive to medication. I don't think there is any question these are disabling. At the same time, I imagine most of us had patients out on disability who certainly COULD be working. Maybe it wouldn't be as easy for them as for you or I, but they could hold down even a typical office job or even a higher-level one without issue, they just played the system. In between those two extremes are a million shades of grey. In MOST cases, I think people would be better served by working if all other things are equal but it is rarely the case where all other things are equal.

Let's take someone with pretty significant depression but also low-ish intellectual functioning, high impulsivity and a...challenging...personality, but not one that meets diagnostic criteria. Is a job going to help improve the depression? Probably. Are they going to get fired within a month of getting a new job? Yup. Are they going to get fired because of the depression? Not necessarily. Once they get off disability, get a job and immediately get fired is that going to introduce a bunch of Axis IV issues? Probably. Are those issues going to prompt a relapse and/or exacerbate the depression? Probably.

Perhaps a bit abstract, but I hope a relatable example for most clinicians. I don't know what the right answer is for that person. I don't think there is a good one. Our systems are set up for black & white rules because - sadly - "thinking" is too much for us to ask even of most professionals. Thus, our systems do an absolute garbage job handling scenarios like the above. There is far more than just psychology in play and your answer will likely differ if you approach it from a legal, economic, political or public health perspective. A room full of smart people could certainly devise a better system than what we currently have, but a bunch of people sitting down together to redesign society overnight is not likely to happen.