News for Women in Psychiatry

MARCIA SCOTT, MD

19 SIBLEY COURT

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

The first section covers the epidemiology of work within the community of severely mentally ill persons and compares it with the relative success of programs for people with physical impairments. Early on, Richard Bonnie wisely notes that while the systems that are designed to assist the mentally ill in getting and staying employed are easily manipulated by people with milder illness and by malingerers, they are less efficient for the severely mentally ill whose difficulties often defeat the programs designed to help them.

The second section is most interesting because it addresses the issues of context-not simply the motivational burdens inherent in mental illness but "working conditions that exacerbate symptoms as well as job requirements poorly tailored to their abilities" Sherry Estroff et al address not-working as a non-rational choice related to work context. "If the satisfaction of working is very great, a person might be willing to pay a high personal cost in emotional discomfort and income in order to find or hold a job" (Bonnie). It’s been my experience that severely mentally ill patients often surmount unreasonable obstacles or stick with jobs well below their capacity balancing, as long as they can, their need for a social identity against their mental discomfort.

The structure of income support programs also forms a context in which disabled workers make choices about when and whether to work. Eligibility programs rarely have work as an outcome, Eligibility for a program or for continuing assistance is usually dependent on an impairment model, a labeling (diagnostic) model, or a needs model. An impairment model begets impairment and ineligible people have a far greater capacity to make a case for their impairment than do very impaired people. The labeling model encourages physicians and patients to support diagnoses that may not be quite fitting but diagnosis has little ability to predict function. A needs model focuses assistance on needs which may or may not be related to work although Davidson points out that work itself is a need and a support for recovery. "While not Sufficient by itself, the recovery of a sense of self as an active, effective, and responsive agent certainly appears to be a necessary and essential part of the recovery process."

Warner and Polak look at specific disincentives to choosing to work. The severely disabled "cannot earn enough to make work a viable economic choice" (Ellwood). They discuss possible incentives like guaranteed work schemes, gradual benefit reduction, wage subsidy, cooperatives using consumers as staff, peer support, pharmacy and housing supports. These are rational solutions based on the rehab model of entitlement but they always come a cropper of the question-how will the assistance be regulated-as if everyone would line up for food stamps. But most American social policy is based on need as the primary determinant for eligibility—the worse you are, the more you get-an approach that is the reverse of what makes most people work-the better you are, the more you get.

Edward Yelin, as a clinician, provides insightful discussions of the specific effects of new workplace structures on the severely mentally ill. He discusses the lack of external structure and the demand for interpersonal contact inherent in the new customer service jobs and the increased demand for autonomous responsibility and productivity even in low-level jobs. What he does not cover is the effect these same changes have had on work withdrawal in people with mild mental disorder -- dysthymia, mild or atypical depression, untreated or regressively treated PTSD. Not everyone can tolerate autonomy or wants traditional success. Some days, I think we would all enjoy some aspects of supported work programs,

The last part of the book covers all the forms of work disability programs and the conflicts between their purposes, eligibility requirements, and content. It points to but does not explain the cost shifting that now occurs between the programs and how that affects the individual’s ability to plan a recovery. It 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 material will be quickly outdated as we move towards new forms of managed care, new kinds of work organizations, integration of health and disability management, changing business cycles, and the changing nature of health, illness, and treatment,

A recent WHO publication reports that by the year 2010 depression will be the commonest cause of illness-related morbidity. None of the contributors to this book mention that a major aspect of work impairment in mental illness is its chronic nature, None of the contributors to this book note that mental illness is simply one of many increasingly common chronic illnesses that place a daily burden on a worker’s ability to get ready for and get through each day of work, sustain employment, or "get ahead." Telling management that they have to diminish the demands they place on people in order to keep them employed and off support programs is not going to make much headway when industry itself is "stressed" by productivity demands. What is needed is some effective theory about how to manage a workforce of people with chronic subtle illnesses like depression, MS, or chronic pain. What is needed is some effective theory about how to manage a workforce that’s getting older, working to age 50, and changing to a new lifestyle and attitude instead of working to 62 and dying at 65. We too depend on the productivity of industry for our lives, but, just as industry did not look to us to solve the healthcare problem, they are not looking to us for help with this problem. in fact, they have not yet formulated what the problem is and if we don’t, we are looking at the next managed care quandary-a swelling population of slightly sick, unemployed have-nots.

Based on a mound of data, Harris’ assumptions are more commonsense than what we have been led to believe over the last 50 years. She outlines what she, and most modern child development students now accept: about one-half the variation in personality, intelligence, and pattern of interpersonal relationships is determined by genes and the other half can be attributed to life experience, that is, parents and adult caregivers; that children, especially slightly older children, learn from other children; that adolescents influence other adolescents in dress, music, language, jokes, and legends; and that both are greatly influenced by the culture-movies, TV, videos, and ads. She presents her theory that group socialization minimizes the lasting influence of parents since hooking up with the group is a predetermined survival strategy. Harris also rejects some standard assumptions that the mother must have physical contact with the infant to bond; that bilingual education slows assimilation with peers; and that dysfunctional families and toxic parents are "to blame." The book is well written and useful for a lay audience.

As a young man, Nielsen lived in a Scandinavia occupied by the Nazis. Normally a rich, civil society,

Scandinavia was suddenly a barren, hungry place. Nielsen, interestingly enough, spent the next five decades doing research on animals such as camels, ostriches and kangaroo rats that manage to live and thrive in lethal environments. I wondered if he, as a curious scientist, ever understood that connection; he never mentioned it.

Nielsen’s adventures in the pursuit of knowledge, the trips to the Amazon and Australia, the descriptions of turtle eggs and odd creatures are well-written and would be especially fascinating for a young adult reader.

M.S.

"Larson, who teaches history and law at the University of Georgia, gracefully documents the history of Darwinism, the theory of evolution and the fits and starts through which evolution became pitted against the Bible and fundamentalist religion."

Rodney A Smolla in the New York Times Book Review.

While some of the young women, particularly those with real support from their own mothers, are doing a fine job, the younger mothers often lack basic parenting skills. Myieka has no books in the house, has never told her son a bedtime story and hits him with a belt when he does not follow her instructions. The older single mothers, on the other hand, talk more about the difficulty of juggling job and child, the lack of time for themselves and their heartfelt wishes and efforts to find fathers for their babies."

Tamar Lewin in the New York Times Book Review.

Less interesting than his life and longer.

The author, an analyst, weaves together Potter’s life and her stories.

A creative but bitter woman, she is better represented by Peter Rabbit. M.S.

Still missing but not much to write about.

Although an early feminist in many ways, Eliot wanted women not to reject but to copy the best in the masculine mind and makeup. A Superior man is the inspirational force behind all the heroines with whom she most identifies: Maggie Tulliver, Dorothea, Romola… Eliot unexpectedly under stood and showed brilliantly just why it is that most men, even the cleverest, do not greatly desire high-mindedness in their partners, and that they can suffer as much as a wife from the alienation it can produce. "

John Bayley in the New York Times Book

The transformation of Hypatia of Alexandria into St. Catherine of Alexandria is arguably the biggest act of chutzpah in hagiography." According to tradition, Hypatia, a pagan scholar and philosopher, "was wise, virtuous, and adored by those who flocked to hear her and a fearsome match for any intellectual opponent." According to tradition, "she was murdered by her Christian enemies in 415 because they could not shut her up any other way.... [A] beautiful young virgin was tortured by a gang of slobbering men before they finished her off." According to tradition, "the colorful tale was expropriated in the Middle Ages and recast with Catherine, a fourth century Christian murdered by pagans."

Beware wise counselors among us. In this book, a "gem of academic detective work," the author punctures these and even later and more interesting myths and finds Hypatia was neither Christian nor pagan, (and was) 60 years old at the time of her assassination. A brilliant mathematician and wise counselor, she was caught in the middle of a struggle for power, killed by "thugs trying to do their boss a favor. "

Anthony Gottlieb, a writer for The Economist, in the New York Times Books Review.