There's something very gratifying about debating a respected teacher. It was 15 years ago when you gave us a wonderful introduction to Freud ... among the first of several reasons I abandoned plans for a residency in radiology.
But ... on to the task at hand. While I largely agree with your closing sentiment, Peter--that if faced with the same clinical dilemma, we'd probably find a similar solution--I'm at odds with you at many points along the way.
First: The therapeutic value of work is real. You put it well: "The clarity of tasks and schedules; the enforced contact with others; the sense of being valued and productive" can be vital. But the EEOC guidelines with their prescriptions for "reasonable accommodations" undermine the very ability of the workplace to provide these features. Under EEOC, people with mental diagnoses who feel "stressed" can get time off and flexible schedules; paranoid people or those who can't get along with others can be assigned to tasks and shifts that require little human interaction; those who can't concentrate or have poor judgment can get one-on-one supervision. Schedules, human contact, and productivity?
Exempting the mentally ill from accepted behavioral standards is a terrible mistake--for the mentally ill themselves. Patients want to fit into society, to act and feel as "normal" as they possibly can. When they can't (or won't) conform to social norms, bending the rules of the workplace--or the courtroom, or schoolroom for that matter--doesn't solve their problems. It's likely to make them worse.
Consider people who are chronically manipulative, who see everyone else as the cause of their troubles, who are emotionally needy, irritable and impulsive. They can change (yes, it's hard work for both patient and therapist) but only when limits are set and social situations reinterpreted. Not when they are "accommodated." In fact, there were times when my unofficial collaborator in treatment was the patient's boss: He reinforced the standards of conduct that the patient and I were also working toward.
"In time," you say, "you and I should discuss [the griping of bosses]. How much of it is justified? Will the act bring chaos or ... new talents to bear in the workplace?" I think the verdict is in, Peter. The total number of EEOC complaints jumped from 9,216 in 1992 to 72,687 last year. Mental disabilities comprised almost 13% of these, the second-biggest single category after back problems (18%). If new talents were waiting to bloom, we would have seen them thrive under the conditions created by the ADA in 1990. Instead, bosses were so confused about the definition of a mental disability and the meaning of "reasonable accommodation" that the guidelines had to be re-explained, illustrated with examples, and re-issued last month.
Of course larger businesses expressed relief, as you note. Not too surprising, though, as they have huge legal and personnel departments to handle regulatory issues just like this. Smaller businesses, on the other hand, are in a panic knowing they can be tied up in grievances that will cost them dearly even if they "win." Ironically, it's the small businesses that have the flexibility and the personal involvement with workers to enact real innovation.
And valued workers, mentally impaired or not, will be accommodated because businessmen are on the perpetual lookout for good workers. (With unemployment at 4.9%, the labor market is the tightest it's been in 20 years.) Take family and medical leave policies: Businesses have had these in effect for years; after all, anything that attracts good employees is good business. The trouble arises when employers are pushed by the government to turn cartwheels for problematic employees.
As a psychiatrist, I have no particular mission to infuse the workplace with my patients--though many mental health advocates want to see more people with mental disabilities at work for the sake of "diversity." I would, naturally, fight for their chance to be hired and to keep a job if they performed well. Just like anyone else. It makes no difference whether the diagnosis is a "personality disorder" or a severe biologically driven disorder like bipolar illness or schizophrenia. Thankfully, the law already ensures that they can't be denied a job or let go on the basis of a diagnosis alone. But it doesn't stop there.
Indeed. Consider the following impairments for which EEOC recommends accommodation: stress intolerance, absenteeism, problems task-sequencing, noncompliant behavior, inability to work alone, reduced concentration, disruptive/erratic behavior, communication difficulty. Reasonable accommodations could be job coaches, flexible work schedules, written instructions, and sensitivity training for co-workers. Peter, do you seriously think that someone who needs one-on-one supervision could really be qualified?
On the other hand, a person who needs a sip of water now and then to combat medication-induced dry mouth should be able to have it. So, when you mention the example of the boss who, until the law required it, wouldn't allow a sip of water on the job, I can only say that this boss sounds like a jerk (though I would wonder if the worker was troublesome in far more substantive ways).
But what about the boss who has a worker with schizophrenia who becomes irritable with co-workers and whose hygiene deteriorates? According to EEOC, the boss can't ask him to shape up. Why? Because there is no "courtesy code" for this person. He was hired to work alone at night and not deal with anyone. More important, the boss can't inquire about the worker's health; he might violate the EEOC prohibition against employer intrusion into the personal affairs of his employee. Does the EEOC realize how egregious this is? This poor man is probably on the verge of a psychotic break but no one can make a move to get him help. According to EEOC, he has to ask for it first, something of a problem when one's crumbling mental state impairs his ability to recognize his condition.
I also disagree with you about the significance of borderline personality disorder (BPD). As long as it is in the psychiatrist's diagnostic bible--the American Psychiatric Association's Diagnostic and Statistical Manual, Fourth Edition--it's fair game as protected species of mental disorder. You go on to say that researchers are finding more and more treatable diagnoses, like depression and anxiety, in people with BPD. Nothing new there; Drs. Hagop Akiskal and Larry Siever have been writing about this for over a decade.
True, it is sometimes possible to tease out a medication-responsive condition in people with personality disorders. If the patient is lucky enough to undergo a character-transformation with the right medication (it does happen, as you point out eloquently in Listening to Prozac) then great. But it's rather rare.
What's more, even when there are biologic underpinnings to problematic behavior, this doesn't absolve the clinician from seeking to alter that behavior by applying its consequences. For example, though we're learning more and more about brain changes induced by drug abuse, some of my addict patients won't clean up until they are arrested, put on probation, and face jail time if their weekly urine specimen is positive. Even people with schizophrenia (one of the most "biologically loaded" mental conditions) are sometimes able to modify behaviors, such as the way they respond to auditory hallucinations, through behavioral modification (though, I hasten to add, I would almost always prescribe medication for them as well).
You--and Freud before you--are right in citing the therapeutic value of work: It structures time; gives purpose; and rewards discipline, responsibility and teamwork. Regrettably, the ADA policy erodes the therapeutic value of work.
When someone with a mental illness is a good worker, the boss has every incentive to accommodate him. But when a problem worker demands and receives accommodation--or demands, doesn't receive, and instigates a complaint--expect waves of backlash discrimination as employers become skittish about hiring a class of people they'll never be able to fire. The workplace will breed the resentment of co-workers and employers as all the worst stereotypes of the mentally disabled are allowed to flourish unchecked. By underestimating the capacity of people to improve themselves, the EEOC then guarantees they won't.
Now Peter, aren't you glad I didn't become a radiologist?