Psychiatry should not be a tool for social justice

A doctor’s primary responsibility is to heal, and all of our efforts and resources should be devoted to that goal.  At times, it is impossible to restore a patient to perfect health and he or she must unfortunately deal with some degree of chronic disability.  Still other times, though, the line between “perfect health” and “disability” is blurred, and nowhere is this more problematic than in psychiatry.

To illustrate, consider the following example from my practice.

Keisha (not her real name), a 27 year-old resident of a particularly impoverished and crime-ridden section of a large city, came to my office for a psychiatric intake appointment.  I reviewed her intake questionnaire; under the question “Why are you seeking help at this time?” she wrote: “bipolar schizophrenia depression mood swings bad anxiety ADHD panic attacks.”  Under “past medications,” she listed six different psychiatric drugs (from several different categories).  She had never been hospitalized.

When I first saw her, she appeared overweight but otherwise in no distress.  An interview revealed no obvious thought disorder, no evidence of hallucinations or delusions, nor did she complain of significant mood symptoms.  During the interview, she told me, “I just got my SSDI so I’m retired now.”  I asked her to elaborate.  “I’m retired now,” she said.  “I get my check every month, I just have to keep seeing a doctor.”  When I asked why she’s on disability, she replied, “I don’t know, whatever they wrote, bipolar, mood swings, panic attacks, stuff like that.”  She had been off medications for over two months (with no apparent symptoms); she said she really “didn’t notice” any effect of the drugs, except the Valium 20 mg per day, which “helped me settle down and relax.”

Keisha is a generally healthy 27 year-old.  She graduated high school (something rare in this community, actually) and took some nursing-assistant classes at a local vocational school.  She dropped out, however, because “I got stressed out.”  She tried looking for other work but then found out from a family member that she could “apply for disability.”  She applied and was denied, but then called a lawyer who specialized in disability appeals and, after about a year of resubmissions, received the good news that she can get Social Security disability, ensuring a monthly check.

How is Keisha “disabled”?  She’s disabled because she went to see a doctor and, presumably, told that doctor that she can’t work because of “stress.”  That doctor probably asked her a series of questions like “are you unable to work because of your depressed mood?”, “Do you find it hard to deal in social situations because of your mood swings?” etc., and she answered them in the affirmative.  I’ve seen dozens—if not hundreds—of disability questionnaires, which ask the same questions.

I have no doubt that Keisha lives a stressful life.  I’ve driven through her part of town.  I’ve read about the turf wars being waged by the gangs there.  I know that her city has one of the highest murder rates in America, unemployment is high, schools are bad, and drug abuse and criminal activity are widespread.  I would be surprised if anyone from her neighborhood was not anxious, depressed, moody, irritable, or paranoid.

But I am not convinced that Keisha has a mental illness.

Lest you think that I don’t care about Keisha’s plight, I do.  Keisha may very well be struggling, but whether this is “major depression,” a true “anxiety disorder,” or simply a reaction to her stressful situation is unclear.  Unfortunately, psychiatry uses simple questions to arrive at a diagnosis—and there are no objective tests for mental illness—so a careless (or unscrupulous) provider can easily apply a label, designating Keisha’s situation as a legitimate medical problem.  When combined with the law firms eager to help people get “the government money they deserve,” and the very real fact that money and housing actually do help people like Keisha, we’ve created the illusion that mental illness is a direct consequence of poverty, and the way to treat it is to give out monthly checks.

As a physician, I see this as counter-therapeutic for a number of reasons.  With patients like Keisha, I often wonder, what exactly am I “treating”?  What constitutes success?  An improvement in symptoms?  (What symptoms?)  Or successfully getting her on the government dole?  And when a patient comes to me, already on disability after receiving a diagnosis of MDD (296.34) or panic disorder (300.21) from some other doctor or clinic, I can’t just say, “I’m sorry about your situation, but let’s see what we can do to overcome it together,” because there’s no incentive to overcome it.  (This is from someone who dealt with severe 307.51 for sixteen years, but who also had the promise of a bright future to help overcome it.)

Moreover, making diagnoses where there is no true pathology artificially inflates disease prevalence, further enlarging state and county mental health bureaucracies.  It enables massive over-prescription of expensive (e.g., atypical antipsychotics like Seroquel and Zyprexa), addictive (like stimulants and benzodiazepines), or simply ineffective (like SSRIs) medications.  And far from helping the downtrodden who claim to be its “victims,” this situation instead rewards drug companies and doctors, some of whom prefer serving this population because of the assembly-line nature of this sort of practice:  see the patient, make the diagnosis, write the script, and see them again in 3-6 months.

The bottom line is, here in America we’ve got thousands (perhaps millions?) of able-bodied people who, for one socioeconomic (i.e., not psychiatric) reason or another, can’t find work and have fallen upon psychiatric “disability” as their savior.  I’d love to help them, but, almost by definition, I cannot.  And neither can any other doctor.  Sure, they struggle and suffer, but their suffering is relieved by a steady job, financial support, and yes, direct government assistance.  These are not part of the psychiatric armamentarium.  It’s not medicine.

Psychiatry should not be a tool for social justice.  (We’ve tried that before.  It failed.)  Using psychiatric labels to help patients obtain taxpayers’ money, unless absolutely necessary and legitimate, is wasteful and dishonest.  More importantly, it harms the very souls we have pledged an oath to protect.

Steve Balt is a psychiatrist who blogs at Thought Broadcast.

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  • http://www.facebook.com/heang.tan Heang Kim Tan

    This is an oversimplification of a very complex issue. Do you
    think justice is about receiving monthly disability payments? This one case
    undermines the millions who suffer from mental health disabilities. If it’s
    really about choice — of being sick or healthy (and working), do you really think
    folks would not chose the latter?

  • http://pajamaproductivity.com Annie Sisk

    This is pretty much bull, start to finish. Radical conservative revisionism masquerading as political commentary, which may be entertaining and reassuring to some segment of the population, but which has no place in thoughtful discussion. If psychiatrists are going to defend their profession, they should probably stop attempting to use that profession in a hamfisted way to sway political process. I’m not even convinced the specific case discussed merits being included in this screed. Of course, we have only the author’s assurances on that point. Sorry, but you haven’t earned my trust – and now you never will, with these sweeping generalizations based on faulty logic.

  • http://www.facebook.com/people/Sheri-Poe-Bernard/1155370103 Sheri Poe Bernard

    I agree with your overarching premise, but to address medical diagnoses as a form of social welfare in the context of mental health is grossly unfair to the mentaily ill of our country who have been marginalized since the Reagan administration. If you want to attack medical complicity in social welfare, go after the law firms who specialize in getting SS benefits for clients. There are more people out there with mental illnesses who need help than there are people out there getting help they don’t deserve. The truely needy far outnumber the malingerers.

  • http://www.facebook.com/profile.php?id=711186615 Laura Davies

    Nowhere in your post do I see any discussion of PTSD.  Nor do I see any question of her prior symptoms. As any psychiatrist knows, just because someone is symptom-free for 2 months does not mean that they have never had any disorder.  This is clearly an unfortunate case but as with the other commenters, I disagree with you that it is widespread. In my experience, it is in fact quite difficult for patients to obtain psychiatric disability.

    • Anonymous

      Dr. Davies, thank you for calling out this article for it’s bias and inadequacy. For a doctor of any specialty to determine a patient’s life course from a single evaluation in a protective environment and without any corroborative testing is unprofessional. As an orthopedist, i have been called to do hundreds of disability evaluations, and I rarely made a final determination without getting items like a functional capacity test, an MRI, or reviewing stacks of medical records. A postal carrier needs to lift 70 pound packages. In the exam room he may look healthy, have good spinal motion, and admit to playing golf. But a FCE may show that his back gives out from a 30 pound load, and records indicate he had 3 previous injuries on the same job. Branding people as abusers of public support systems without adequate medical evidence is unethical and immoral.

  • Payne Hertz

    “But I am not convinced that Keisha has a mental illness.”

    It is fairly obvious that quite a few other doctors agreed that she did, otherwise she never would have gotten SSDI. If she got SSDI as quickly as you suggest she did, then even Social Security’s doctors must have agreed she qualified, as they are paid to find any reason possible for rejecting claims.

    You overestimate the ease with which people who have severe disabilities can get SSDI. Even with extensive documentation, the process can take years and it is normal for people to be rejected multiple times before being forced to get an SSDI lawyer, who rarely do much but present the same medical evidence that has already been rejected before a judge, who makes the final determination. Few lawyers will take a case before you’ve been rejected at least twice,  by which time at least two years have passed during which the genuinely disabled person who cannot work receives no benefits. You also have to work and pay into the system for at least 10 years to qualify for SSDI, so your insinuation that people like “Keisha” are freeloaders who are unwilling to work is pure fiction.

    In the US, it is normal to have to hire a lawyer and give him a percentage of your benefits up to a fixed amount in order to have any chance of qualifying for the benefits under a system you worked and paid into for years. Only a small minority receive benefits on the first try, and usually these are people with clear-cut disabilities so pronounced that even the unethical hacks who work as vetters for the system cannot deny it.  If you are disabled, you should get benefits promptly; if you are not, then you should be denied benefits. Why is it, then, that the majority of SSDI recipients have to wait for years and pay for a lawyer to qualify for benefits?

  • http://twitter.com/HealthCulture Jan Henderson

    I think the larger point here is that to label and medicate those who are
    not in fact mentally ill is a sad, unfortunate, and unjust way to avoid
    addressing the larger social issues that bring such an individual to a
    psychiatrist in the first place.

  • Anonymous

    Folk, including doctors, who do not live in urban war zones cannot legitimately question the impact on community  residents. Women, in particular, bear the brunt of anti-social lawlessness. Some people can cope; others are severely impacted psychologically. Try living in communities where this happens:  http://www.scribd.com/doc/50309493/NYPD-2010-Murder-stats. Even children are afraid to leave their home for fear of getting randomly shot, and they say so. You can’t question the level of anxiety until you live in  their shoes. I know. I live in a community like this.

  • sydney moirangthem

    I have a question for you. On what basis are you saying or claiming that SSRI’s are ineffective? Agreed we really don’t have a diagnostic procedure or an intervention to make a diagnosis of a mental illness but is there any more scientific way out with our current advancement of science & medicine? Are PET & SPECT really ready as diagnostic stools now & if yes, how many patients can actually afford them? Should we stop treating patients just because or diagnostic instruments are not yet perfected? Are we really different from the other disciplines of medicine of diagnosis is the only question? How many different definitions & different values of blood sugar were there for Diabetes Mellitus till the current definition was agreed upon? Their definitions & classifications are changing & so is our (though our system is not a quantitative one), & what is wrong in that? This is how science progresses & people go ahead. Being critical is fine but going overboard is not desirable.

  • http://twitter.com/cookiecat57 cookiecat57

    “And when a patient comes to me, already on disability after receiving a diagnosis of MDD (296.34) or panic disorder (300.21) from some other doctor or clinic, I can’t just say, “I’m sorry about your situation, but let’s see what we can do to overcome it together,” because there’s no incentive to overcome it.  (This is from someone who dealt with severe 307.51 for sixteen years, but who also had the promise of a bright future to help overcome it.)”

    What a cop-out. Of course you can say that and you should. The notion that someone on disability has no incentive to improve their situation is ridiculous. It goes to quality of life and provides hope. Are you a psychiatrist or not? Your attitude towards these clients is appalling. You are doing them a disservice by treating them since it appears that you have already passed judgement on them.  Further, how does your bulimic client figure in to this argument? It makes no sense.

  • http://twitter.com/balts Dr Steve Balt

    cookiecat:

    “The notion that someone on disability has no incentive to improve their situation is ridiculous.”

    I agree in principle, but in practice, people like the one described in this article really have no incentive to improve.  Where are the jobs for men and women like Keisha?  How will they pay for health care once they lose their Disability Insurance?  I’ve worked in this community for 3+ years and it’s profound.  As a psychiatrist, I really feel helpless (especially when there’s not much of a “mental illness” in the first place).  I feel like a social worker would be more effective… and that’s not to disparage social workers, but to state that the care they provide would be much more relevant (and a lot cheaper).

    “you have already passed judgment on them”

    No.  Someone else has passed judgment on them: the disability evaluators, a lawyer, a judge.  When I see a new patient, my guiding principle is that I can HELP my patients (and, fortunately for psychiatry, most illnesses– even when severe) can be overcome to a significant degree with medications and/or therapy.  If that’s “judgment,” so be it.  Unfortunately, patients tend to identify with the “judgment” that they’re disabled, not with the judgment that their disability can be overcome.

    “your bulimic client”

    307.51 was referring to the author’s own experience.

    • http://twitter.com/cookiecat57 cookiecat57

      “No.  Someone else has passed judgment on them: the disability evaluators, a lawyer, a judge.  When I see a new patient, my guiding principle is that I can HELP my patients (and, fortunately for psychiatry, most illnesses– even when severe) can be overcome to a significant degree with medications and/or therapy.  If that’s “judgment,” so be it.  Unfortunately, patients tend to identify with the “judgment” that they’re disabled, not with the judgment that their disability can be overcome.”
      Your responses still don’t sit well with me. I’m still completely bothered by the tone of this piece. I’m not disputing the validity of your observations; however, by using an interview with a new client to support your claim, I can’t help but feel that you have an inherent predisposition to suspect the diagnosis when treating clients in this (I’ll call it out here) predominantly African-American population.  I wonder if you would have the same skepticism when interviewing a middle class white woman from the suburbs. This is what I mean when I’m discussing judgement.

  • http://twitter.com/balts Dr Steve Balt

    “you have an inherent predisposition to suspect the diagnosis when
    treating clients in this (I’ll call it out here) predominantly
    African-American population”

    Now, who’s jumping to conclusions?

    Who said Keisha was African-American?

    Who said middle-class suburban whites can’t be marked as “disabled” and
    lose hope for recovery as a result?  I agree with you, it happens *less*
    frequently in this population, but that’s not my fault.

    I must say I’m disturbed by the conclusions/assumptions being drawn
    about my underlying philosophy (or racial bias)– especially the comment that this
    represents “radical conservative revisionism”, when in fact my true goal
    is to empower and enfranchise each of my patients, regardless of socioeconomic or ethnic background.  Personally, I can’t think of a
    more “liberal” ideal.

    Incidentally, the post says nothing about the large number of patients
    who are *truly* disabled (yes, many of whom legitimately suffer from a
    “hidden” disability and deserve society’s support).  It simply speaks to
    the very large number of generally able-bodied folks who can’t even say
    *why* they’re disabled (but wear this label with misguided pride) and
    to the doctors who, for purposes of “empowerment” or out of their
    “progressive” mindset, willingly label such people in an equally
    misguided way.

  • http://pulse.yahoo.com/_6C65YWGCC7P5C6CGMMBK7VMFXE JenniferL

    A bit too simplistic. 

    That being said, SSD needs more reviews.

  • Anonymous

    I think you got yourself in over your head with the Keisha example. 

    In my practice, I see folks who I feel are abusing the system.  Most obviously abusing are the guys on disability who work in trades under the table and spend a significant amount of money each month on things like gambling, and cocaine…My favorite line in morning rounds is, “It’s enough to make ya want to join the Tea Party!”

    However often, I am caring for someone who I believe is in dire need of SSD, and can’t get it, and I ask my social worker to give them the card for the same lawyer who got the benefits for the guys mentioned above who make me cringe.

  • Anonymous

    I applaud Dr. Balt here for his ethics, honesty and exposure of the majority of the mental death profession.  However, I hope he is equally as reluctant to give the latest fraud fad stigmas like bipolar, ADHD, depression, which will lead to a bipolar diagnosis due to the useless but deadly SSRI antidepressants causing mania, suicide, etc.  I only hope that Dr. Balt applies the same standard to the so called higher classes in that he doesn’t apply these fraud labels VOTED in by the white male old boy network of the mental death profession for its life destroying satanic bible, the DSM, that all medical/mental personnel are forced to use to get paid by insurance, government, etc.  Dr. Susan Weitzman in her great book, NOT TO PEOPLE LIKE US, exposes how domestic violence, narcissistic abuse, work mobbing and bullying, etc. are equal opportunity miseries in the upper classes too.   Yet, the mental death profession gives the VICTIMS life destroying stigmas like bipolar, paranoia, ADHD, borderline personality disorder, etc. per Dr. Carole Warshaw, Dr. Judith Herman, Dr. Frank Ochberg, Dr. Peter Breggin, etc.to discredit the victims and aid and abet their fellow abusers and cohorts in crime. Dr. Balt should focus on how psychiatry ensures that those with less power and money are silenced, discredited and routinely destroyed by the mental death profession to deny them any justice for the tons of abuses, traumas, malpractice and losses they suffer from the psychopathic power elite of whom they are chief with few exceptions.   If psychiatry is not going to help poor people in dangerous neighborhoods obtain social justice, they should abolish themselves with their bogus labels and fables they invent with no scientific evidence whatever despite their great pretense to the contrary to push their lethal drugs in bed with BIG PHARMA, so they don’t deprive all of society of any hope of getting justice when such malignant narcissists like themselves commit crimes against normal people.

    So, Dr. Balt should focus his attention on the fact that psychiatry IS ONLY A MEANS OF SOCIAL CONTROL FOR THE POWER ELITE as described by Dr. Thomas Szasz, Dr. Peter Breggin and other honest, noble critics.  This power elite has dictacted that people suffering abuse, poverty and other social inflicted trauma by the power elite directly or indirectly will be profit centers for the multibillion global BIG PHARMA plutocracy by forcing as many as possible with emphasis on the most powerless and vulnerable to be given a fraud mental death labels and take their toxic poison psych drugs to get money to survive.  This also helps shorten lives 25 years to help with their nazi euthenasia throughout the world.  The Boston Globe did a big exposure of the Social Security Disability System and showed how it is an alternative welfare system or the only welfare system.  Psychopathic George W. Bush with his huge ties to BIG PHARMA like Eli Lilly focused much effort on forcing these bogus labels and toxic drugs on as many as possible from the cradle to the grave.  Only psychopaths could have invented the bogus “biological” psychiatry mental death profession as it stands today and those who aid and abet it are just as evil if not more so since they should know better, but will sell their souls for profit,  power and status.

  • Anonymous

    It depends on the perception of the physician whether health is considered a social good.  If yes, then social justice that oversees the fair distribution of social good has to include health.  Instead of debating about the nature of mental health in an individual’s well being, why don’t psychiatrists lobby for more funding from the NMHI to study mental disorders.  Why do the majority of psychiatrist choose to promulgate and cooperate with the broken disability system in America? 

  • Joe Kosterich

    I agree  It is too easy to medicalize life and find medical “excuses” for behaviour that people may not like

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