Disordered Policies

To the editor:
Sally Satel’s "Treating Insanity Reasonably" and Heather Mac Donald’s "Welfare’s Last Vietnam" (Winter 1995) form a terrific one-two punch. Dr. Satel’s article illustrates how deinstitutionalization of mentally ill individuals failed in the past by fundamentally misunderstanding the nature of serious mental illnesses, which we now know are brain diseases, and by permitting civil rights lawyers to change commitment laws so that mentally ill individuals are guaranteed the right to remain mentally ill. Ms. Mac Donald’s article illustrates how these past mistakes are being continued in the present by miscategorizing addictions and childhood behavioral problems as "diseases," thereby qualifying the person for SSI, SSDI, Medicaid, and other perpetual federal disbursements.

A Martian arriving in New York today would be extremely perplexed by the mental illness treatment system that has evolved. We regularly release people who have brain diseases from hospitals without insuring that they get the medicine they need to prevent their illness from recurring. When they do relapse, we house them in public shelters, some of which use the same hospital buildings that were closed down when these people left the hospitals (Ward’s Island, for example). We reward drug and alcohol addicts with payments for continuing to be addicted, and we reward the families of children who misbehave with payments as long as they continue to misbehave. The Martian might well wonder just who really has disordered thinking.

E. Fuller Torrey
M.D. Health Research Group Public Citizen Washington, D.C.

To the editor:
Contrary to Ms. Mac Donald’s claims, federal disability programs do not reward people for a "chaotic upbringing," lack of a "work ethic," or "simply antisocial or even criminal behavior." In fact, especially for the population that is her principal focus?people with mental illness, deprived of the opportunity for either rehabilitation or work?disability provides a bedrock of support.

Ms. Mac Donald writes that a 1982 case in Minnesota was successful in "challenging the Social Security Administration’s evaluation of non-severe" mental impairments. In fact, the plaintiff class in that case was composed exclusively of people whom SSA itself had identified as having severe impairments. The most devastating evidence came from SSA’s medical director in Chicago. He wrote in a memorandum that it was "practically impossible" to gain benefits "for any individual whose thought processes are not completely disorganized, (who) is not blatantly psychotic, (and who) is not having a psychiatric emergency requiring immediate hospitalization."

So Congress demanded new rules. In writing them, SSA, far from departing from "traditional medical impairments," based them on medical criteria from the American Psychiatric Association’s Diagnostic and Statistical Manual and functional standards derived from reviewing psychiatric literature and consulting with the American Psychiatric Association, the American Psychological Association, and other experts in the field. People who lack a "work ethic" or who have only a mild impairment are not eligible for benefits under these rules.

Children’s SSI is designed to provide benefits only to the most severely disabled children. Ms. Mac Donald’s charge that any child claiming emotional disturbance is eligible is certainly not supported by the eligibility rules. The allegation that non-disabled or only mildly disabled children are being granted benefits certainly warrants investigation and correction, but it is no basis to fiddle with the rules.

In the end, I agree with Ms. Mac Donald that the real question is about dependency. No disability program should foster dependency. But in a society where access to rehabilitation for people with mental illness is scandalously limited and where the work incentives of the disability programs are inadequate, denying subsistence benefits will not end dependency.

Arthur T. Meyerson
M.D. Clinical Director Community Mental Health Center Newark, N.J.

To the editor:
While it is surely valid to cite advocacy lawyers and the growing culture of entitlement as the primary culprits in the increase in disability enrollment that Ms. Mac Donald describes, these factors do not account for the entire problem.

Virtually every public agency that deals with the consequences of social disorganization?from the courts and schools to family service agencies to mental hospitals?is experiencing an unmanageable explosion of demand. These institutions are not being overwhelmed by crafty advocates and wily grifters; they are being swamped by genuine human misery at just the time that tax resources are becoming more scarce.

Schools, courts, family support agencies, and mental hospitals are not conducting outreach activities. They are doing triage, writing off people whom a decade ago they would have tried to help. The urban dustbin is growing ever more full, so it should not be surprising that disability programs are absorbing some of the overflow. As we reform the disability programs, we must also keep the safety net under those for whom other alternatives have failed.

Hal Bergan
President Bergan & Associates Madison, Wis.

Heather Mac Donald responds:
Dr. Meyerson denies that federal disability is shifting its focus from medical to social pathologies. I would refer him to the case of Robin Smith of Brooklyn. Now in her late thirties, Smith has been addicted to heroin since her early teens. She dropped out of high school at 14 to have her first child; she has since had four more. She has worked only once, but quit after six months.

Smith applied for SSI benefits in 1986, claiming that her asthma, bad nerves, and drug use prevented her from working. She provided no evidence of severe asthma, but a psychologist diagnosed her with "antisocial trends that result in disturbing her ability to function in the society as a productive or self-supporting member." In 1991, a federal judge awarded her benefits for heroin use.

Many of those who have entered the rolls over the past decade may indeed be unable to function in society, but often that inability to function is selfinduced. I fully agree that mental illness can tragically incapacitate. But it shortchanges the truly mentally ill when the government devotes limited resources to problems that originate with an individual’s bad decisions.

Children’s disability may well have been designed for only severely disabled children, as Dr. Meyerson claims, but it is not working that way in practice. Teachers tell of parents who, after failing to show up for a single parent-teacher conference, suddenly beat down the school door when they get wind of the SSI program. It is not the absence of SSI benefits that is preventing such parents from caring for their children, but rather the parents’ own irresponsibility.

Mr. Bergan and I do not fundamentally disagree. No one would dispute that there is an enormous amount of distress in the inner cities. But to ask the disability program to alleviate it is misguided. The program has been pulled in so many directions that its original directive?to assist those who truly suffer from severe disabilities?has been lost.


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