You say I'm sentimental about employers. Not so. I'm practical--I believe that individuals (employers) working in their own self interest do a better job than a government that's buffeted by political forces and doesn't have the expertise to make decisions about what's best for the mentally ill worker. You're right, though, we certainly do spend our time with different types of patients. Yours are employed and educated; probably mostly depressed, anxious, and neurotic. Mine are addicts, some of whom are employed, but few of whom are educated beyond high school. A large number have concurrent diagnoses of depression or personality disorder. You and I established early on that employment may be one of the most powerful therapies around, but instead of worrying, like I imagine you do, whether a patient's boss is going to give her time off to see her shrink, I worry whether she's ever going to have a boss.
This is because the government ends up giving so many of my patients incentives not to work. Let me describe how patients are kept from perhaps the best therapy they can get: a job. My clinical population comprises drug abusers who are maintained on methadone. That means they are no longer addicted to heroin but may actively abuse cocaine, alcohol, or marijuana. In other words, they're not addicted to these drugs, but use for pleasure or to reduce anxiety. In either case, the episode of use is generally fairly brief.
Among my patients, many of the women get AFDC and so receive a monthly government income check (and the food stamps, public housing vouchers, and Medicaid) for simply having healthy children under age 18--the problem is that the kids are often school-aged and don't require an at-home mom. Other men and women get the benefits for being HIV+. Still others get it for mental disability because they once suffered a bout of serious depression (perhaps drug-induced). A lot of these individuals have been in remission for years, yet they are still considered disabled and eligible for benefits by the Social Security Administration. Naturally, in all these examples, cash benefits are used to finance the purchase of illicit drugs.
In the case of patients infected with HIV, I don't mind the Medicaid so much, since some of them have to take triple anti-AIDS therapy which is very expensive; but the income, food, and housing supplements are uncalled for. As a rule, these folks aren't sick--recall Magic Johnson's second career as an HIV+ player--but, worse, the cash creates a perverse incentive not to work. Most of my patients receiving federal benefits would never get as good a package (health insurance, a guaranteed monthly income, food stamps, housing discounts) as a burger flipper or delivery man. Adding insult to injury, those who are prescribed anti-AIDS therapy often don't take the pills responsibly, thereby creating opportunity for viral mutation that will make them and anyone they infect potentially harder to treat in the future.
As you know, I don't support the idea of addicts receiving public entitlements directly, if at all. At the very most, we should consider entitlements for addicts akin to a treatment scholarship: funds should be directed to the treatment program or a nonprofit agency working with the program. These agents would see to it that rent and food costs are paid directly to vendors, and would reward recipients for negative urines and treatment compliance with whatever discretionary cash remains.
For really hard-core addicts, we need more residential slots for long-term treatment and resocialization. I wouldn't mind if the government paid for that. I'm sure we could increase the number of slots nationwide--the current count is pitifully small--if we stopped funding perverse incentives and directed those funds to building a residential treatment network. Now, there's also a mirror-image problem: that of mentally ill people who want to work or enter vocational rehabilitation programs but are too afraid to give up their federal disability benefits for fear of losing Medicaid. They have illnesses, like major depression, bipolar illness, even schizophrenia, and can do quite well most of the time when they take their medication. Sometimes, unfortunately, they suffer "flare-ups" and require either a hospital stay, increased outpatient visits, or a switch to a new, expensive medication. Without Medicaid, they'd be wiped out financially and unable to get care. Right now there are effectively no mechanisms that allow these individuals to continue receiving Medicaid (or Medicare); they must either take the entire entitlement package, or nothing.
The larger problem facing psychiatrists (and the government) is not how to force employers to cater to the idiosyncratic needs of the mentally ill--remember, I'm all for catering, but by a boss who values a good employee, mentally ill or not, not by one who is mandated to do so--rather it's how to get many of our patients into the workforce and out of the dependency trap set by a well-intended federal system. As one with faith in federal intervention, perhaps you can defend that system.