Summer 2000, Vol. 8, No. 3.

Book Reviews

Mental Disorder, Work Disability, and the Law,
ed Richard J Bonnie, John Monahan,
University of Chicago Press, Chicago, Il, 1997, 308 pp, cloth.

By Marcia Scott, M.D.,
Boston, MA

With chapters by psychiatrist-law professors and policy wonks, professionals with a social medicine slant dominate the book. They cover workforce participation and barriers to work for the mentally ill - barriers intrinsic to specific illnesses, to particular social contexts, to work systems, and barriers that arise from the unintended consequences of support and entitlement programs.

The first section covers the epidemiology of work. The author compares the results of programs within the community of severely mentally ill with the relative success of similar programs for people with physical impairments. Early on, Richard Bonnie wisely notes that while these kinds of entitlement and assistance programs were designed to assist the mentally ill in getting and staying employed, the structure of the program often defeats the people they were meant to help. Meanwhile, they are easily manipulated by people with milder illness and by malingerers. The second section is most interesting because it addresses context - including working conditions that exacerbate mental symptoms and job requirements that are poorly tailored to the abilities of the severely mentally ill.

Other chapters cover how the structure of income support programs influence whether and when disabled workers choose to work. Eligibility criteria for most programs don't support work as an outcome. Continuing eligibility is usually based on an impairment model, a labeling (diagnostic) model, or a needs model. Ineligible people have a far greater capacity to make a case for their impairment than do very impaired people. Eligibility based on labelling encourages physicians and patients to support diagnoses that are not accurate and give an estimate of the individual's current or possible ability to function. Need is the basis of most American social policy, but that only fosters the notion that the worse you are the more you get - an unencouraging model for promoting successful work behavior since at work, it's more likely that the better you are the more you get.

Another section by Warner and Polak explores specific disincentives to choosing to work. Notably, most people who are severely disabled cannot earn enough to make work a viable economic choice (Ellwood). They discuss possible incentives such as guaranteed work schemes, gradual benefit reduction, wage subsidy, cooperative work that uses consumers as staff, peer support, and pharmacy and housing supports. These are rational solutions based on a rehabilitation model of entitlement, but rehabilitation solutions seem always to come a cropper of the complaint - how will the assistance be regulated - so only the "deserving," the needy, get help?

Edward Yelin, clinician, provides insightful discussions of the specific effects of new workplace structures on the severely mentally ill - the lack of external structure and increased autonomy in these jobs, as well as the demand for greater interpersonal contact, high frustration tolerance, and high productivity even in low-level jobs. He makes the point that not everyone can tolerate autonomy or wants traditional success but what he does not discuss is the effect these changes have also had on work withdrawal in people with mild mental disorders - dysthymia, mild or atypical depression, or untreated or regressively treated PTSD. It's hard for me to imagine how people with mental illness will survive the new workplace: on some days, I think we'd all enjoy some aspects of supported work programs!

The last part of the book descirbes all the forms of work disability programs, the conflicts between their purposes, eligibility requirements, and content and how those differences result in both cost shifting and obstacles to recovery. This part of the book is remarkably up to date on issues like private work disability insurance, workers compensation, SSDI, as well as the Vocational rehabilitation programs that fit with each of these. One drawback is that this material is presented with very little theory so that the content will be quickly outdated as we move towards new forms of managed care, new kinds of work organizations, integration of health and disability coverage, changing business cycles.

I would have been interested in hearing these authors discuss their subject in the light of the changing nature of health, illness, and treatment. A major aspect of work impairment in mental illness is its chronic nature. Increasingly, mental illness is just one of many increasingly common chronic illnesses that place a daily burden on a worker's ability get ready for, and get through each day of work, sustain employment, or get ahead. Employers have never been adept at managing chronically mentally ill workers. As all illness becomes chronic they will be faced with keeping a workforce of people with chronic subtle illnesses such as depression, MS, or chronic pain employed and productive. They will also need some effective theory for designing processes that manage an older workforce that's working to 50, then changing to a new lifestyle and attitude rather than working to 62 and dying at 65. Management in most large companies is already stressed by the productivity demands. Its unlikely they even understand they will have to adapt their demands to keep their jobs filled and people off support programs. When they are confronted, they are not likely to look to us for help with this problem anymore than they looked to medicine or psychiatry to solve the health care problem. When they eventually formulate the problem they are likely to proceed to do something simple and simplistic. If we don't step forward with an alternative, effective way of managing a work force with chronic illness, we will be looking at another quagmire like managed care: a swelling population of slightly sick, unemployed, have-nots.

 
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