As a practicing psychiatrist in Pittsburgh, I have become all too aware of a disturbing and potentially dangerous way in which Social Security Disability is now being deployed for psychiatric patients.
In years past, a person who applied for SSI/Disability would have his or her psychiatric records requisitioned from a treating psychiatrist. The applicant would then also be evaluated by a second psychiatrist contracted to the Social Security Administration and not linked to the patient. In addition, the applicant was required to be seen by a contracted psychiatrist annually to ensure that he or she indeed remained disabled and qualified for the subsidy.
In recent years, however, I am finding patient after patient placed on disability, often after an initial evaluation with me, without any attempt made to check if that individual remains disabled, even years after the initial determination.
For instance, I queried a middle-aged patient I've treated for four years as to how he is now supporting himself. "Well, I am on Social Security Disability," he replied.
I asked him why he remains on disability. "I have depression." But you are no longer depressed, I countered. Indeed, he has been free of symptoms since a few months after beginning treatment three years ago.
He was taken aback briefly, not expecting the mild confrontation, before he confided sheepishly, "I ... could never make the kind of money I get from disability from a job."
It needs to be said that this individual is also quite physically healthy. He has essentially been put on disability without any oversight and will remain so for the rest of his life under current conditions.
Another, more responsible patient, 50 years of age, recently applied for and was granted SSI/Disability for a bipolar disorder she had overcome five years ago! It seems she had genuinely tried to find employment after losing her job recently and even now would much prefer to work, but no jobs were available to her. She too will now be on "disability" for years to come.
I now see 40 or more patients with similar stories.
There are many problems with this permissive policy.
First, it encourages fraudulent behavior on the part of applicants, with a blind eye, a wink and a nod from the Social Security Administration. This policy feeds deception in a population already struggling with maintaining internal and external limits.
Years back, I evaluated a patient on SSI/Disability for an ostensible leg injury caused by, from her report, a money cart falling on her in a casino in Reno! She was suing the casino. Her boyfriend was also on disability. The casino hired a private investigator who filmed her playing basketball, crawling under her car and carrying heavy packages from the supermarket, never requiring so much as a cane for help with her ostensibly injured leg!
Second, this SSI/Disability policy is destructive and counter-therapeutic.
Here is a typical scenario: A patient makes an appointment with me for what are often, though not always, legitimate psychiatric symptoms. Then, within a week or two of my evaluation, I receive a request from Social Security for a copy of my report (the patient has signed a release for this information).
The patient has often applied for disability prior to seeing me, and hardly ever volunteers that he or she has done so. The patient is awarded the disability before our next visit! By the third visit, often within two months of the initial evaluation, the patient has fully recovered from the initial "disabling" symptoms.
If disability has not yet been granted, the initial symptoms seem to worsen, then to improve only after the first disability check arrives. That is, the patient has a vested financial and psychological interest in not getting better while still applying for disability.
Indeed, I have seen none of my patients improve, and most deteriorate, while disability is still being processed. They then remain symptom-free but are unable to resume working for the remainder of their lives.
Allowing patients essentially to define themselves, and be defined by officialdom, as "disabled" may provide them a basic income, but it also lowers their sense of self-esteem and competence. These people learn to define themselves as "sick"; why else would they have been awarded disability? If they were not disabled prior to the application process, they will surely become psychologically, if not symptomatically, disabled once on the government dole.
A number of years back, a professor in New York sent his students out on a project to claim a disability and request subway seats from older individuals during rush hour. When they reported to him that this was an exquisitely painful task, he tried it himself. He then found that no sooner did an elderly person relinquish his or her seat, than he, now sitting comfortably during rush hour, began to feel physically more and more ill. It is as if the mind induces illness in order to justify the "disabled" definition.
Finally, current disability policy has got to be exceptionally costly to our already overspent national budget. If I have this many individuals on my one-man case load and do the appropriate math, we must be pouring many hundreds of millions of dollars down the national drain supporting mental health patients unnecessarily while at the same time weakening and injuring their adaptive capacities -- a lose-lose-lose situation for the patient, the federal budget and the national psyche.
Mental health patients are more than a collection of mental symptoms. They are first and foremost fully rounded people who retain multiple adaptive capacities. Their symptoms often improve dramatically even within weeks of starting treatment. They often retain full capacity for productive work, and they should not be allowed to become life-long dependents on society due to misguided government policy.
Dr. Marnin E. Fischbach practices psychiatry at several locations in the Pittsburgh area and lives in Squirrel Hill.