When first we met, you were a disgruntled medical student, headed for a career in radiology. I was one of your psychiatry instructors. I encouraged you to consider becoming a psychiatrist and then (since you were already a poet) a psychiatrist-writer. And here you are, contributing slashing right-wing essays to the New Republic and the Wall Street Journal. I feel toward you the way the Alan Alda character does toward his son in Woody Allen's recent film, Everyone Says I Love You. I'm delighted by your success, but did you have to turn out to be a conservative?
This month, you and I independently wrote New York Times op-ed pieces on the mentally ill in the workplace. The occasion was a set of guidelines, issued by the Equal Employment Opportunity Commission, on the application of the Americans With Disabilities Act to employees with mental illness. The gist of the act as a whole is that employers must supply "reasonable accommodation" for disabled workers--ramps for workers in wheelchairs is the usual example. Employers can still fire disabled workers if they break rules that would result in any worker's being fired. And accommodation is never to be applied retroactively--once a worker is fired, he or she is no longer covered by the act. But disabled workers can request that the workplace be modified to allow them to continue to do their jobs. As regards mental illness, certain disorders are excluded--for example, kleptomania, pyromania, and any condition involving current illegal-drug use. And merely having a mental illness is not enough; the person must be disabled by the mental illness.
Here is an example the EEOC gives of reasonable accommodation: A retailer does not allow cashiers to drink beverages at checkout stations. An employee on a psychotherapeutic medication needs to drink beverages to combat a drug side effect, dry mouth. As accommodation, the employer might modify the policy against drinking beverages or allow the employee more frequent work breaks. This sort of requirement prevents covert discrimination--disciplining the mentally ill on the grounds that they have "broken rules" that are only marginally related to job performance.
The act has been in effect since 1990, and from the start it has been understood to extend to the mentally ill. The EEOC's directive is meant to bring order to the process, so that employers do not have to guess at their obligations and then be proved wrong in the courts. Some larger businesses have expressed relief--now they know what the rules are. But there has also been griping by employers who fear they can be sued for just anything. In time, you and I should discuss that griping: How much of it is justified? Will the act bring chaos or will it bring new talents to bear in the workplace, as the expansion of occupational civil rights is meant to do? In time we should try to approach those questions, from our special point of view as practicing psychiatrists.
But in our op-ed pieces we disagreed about a different issue. I said that the act will be helpful to the mentally ill; you said it will hurt them. For both of us, a decisive issue is the therapeutic value of work. I argued that the well-being of the mentally ill often depends on the structure work gives their days--the clarity of tasks and schedules, and the enforced contact with others. The sense of being valued and productive is also crucial. Work often helps save the seriously mentally ill--the depressed, manic, obsessed, and schizophrenic--from the worst consequences of illness and sometimes from recurrence of illness altogether.
I take your argument to be that any occupational accommodation will indulge the mentally ill to the point that work no longer benefits them. If patients can bend rules in the workplace, they learn a bad lesson, that the world must acquiesce to them rather than the reverse. You say that, had it been in effect, the new EEOC directive would have ruined your treatment of an impulsive and self-centered woman with "borderline personality disorder" who needed to learn to internalize "limits" and to conform her behavior to others' expectations.
Well, perhaps. Surely a doctor with your talents could have treated the woman even if an employer had modified her work conditions--especially since your patient would still have been required to do her job. The world has a way of punishing narcissism; you and your patient would have had plenty left to chew on. A patient must face reality, but once the EEOC guidelines are in effect, they are the new reality; one of the lessons of psychotherapy is that social realities can change.
Besides, you know that you have chosen a marginal example. "Borderline personality disorder" is on its last legs. For some time, the Harvard psychiatry professor George Vaillant has traveled the country challenging colleagues to produce a single patient who has "borderline personality disorder" and whose condition is not better explained by an alternative diagnosis. No one has met the challenge. At the annual meeting of the American Psychiatric Association this week, the researcher Hagop Akiskal hosted a symposium titled "Borderline Personality Disorder: More Treatable Under Different Names?" He had in mind the minor depressions, certain anxiety disorders, variants of manic depression, and, of course, the addictions. Had you treated your patient under one of those (more intellectually defensible) headings and limited her accommodation demands to the direct effects of the illness, many of your worries would have disappeared.
I see your op-ed piece less as an attack on EEOC guidelines than as an obligatory restatement of the new right-wing political correctness: We must all put our shoulders to the wheel and our noses to the grindstone, grit our teeth and put our backs into our work and build a better America--by pitying the overburdened employer and scorning the overindulged worker. Yes, there are reasons for concern about the Americans With Disabilities Act. I am sure some will emerge in our discussion. But I hardly believe that you think the act will on balance injure the mentally ill.
Meanwhile, I think we start with one major point of agreement: The professions psychiatry and psychology must do a more honest job of delimiting illness. Perhaps this will be a side benefit of the act. It will cause employers to pressure professionals to do that job--not to throw out the act but to make a clearer accounting of the sorts of mental illness (would you begin by agreeing on schizophrenia?) that will most benefit from being accommodated at work. Or do you really think that the marketplace is peopled exclusively by virtuous employers, men and women who never discriminate against the mentally ill--and that the mentally ill are all freeloaders, lying in wait for the chance to expose their own disabilities and use them as clubs with which to extort concessions?
It is strange to spar with you over these matters of social policy, because I suspect that, faced with a particular clinical dilemma, you and I would mostly agree.