Who's Crazy Now?
Words like "mad," "insane," and "psychotic" have long been banished from our official language, in an effort to reduce the stigma of the severest "mental illnesses." In one sense this has succeeded -- nearly everyone is willing to say they have a touch of depression, paranoia, or some other mental illness.But in the process the special needs of those we once called "insane" are too often forgotten.The American Psychiatric Association created a public policy nightmare when DSM III, their l980 diagnostic manual, abandoned the time-honored distinction between incapacitating "psychoses" and less severe "neuroses," and democratically termed everything a "mental disorder" -- from manic-depressive illness ("bipolar disorder") to social anxiety and even smoking.The Equal Employment Opportunity Commission (EEOC)'s recent guidelines for dealing with mental disability in the workplace illustrate the "expressive disorder" that erupts whenever policymakers try to help the mentally ill. The l990 Americans with Disabilities Act (ADA), which the guidelines are interpreting, covers mental as well as physical disabilities. But if "mental disorders" afflict "more than one in four" Americans, as New York Times headlines reported in l993, or worse, "one in two," as reported a mere ten months later, is half our workforce eligible for accommodation under ADA?The DSM offers no answers. The introduction to DSM IV, the latest volume, warns that its diagnostic criteria and system of classification (which make all "disorders" equal in the eyes of insurance companies) are irrelevant for legal definitions of impairment or disability.Since the DSM is no help, The National Alliance for the Mentally Ill (NAMI) has tried to focus policymakers' attention on the special needs of people who suffer the severest mental illnesses and their families. Their educational and lobbying efforts focus on a group of severe biologically based illnesses which can often be treated successfully with drugs: schizophrenia, bipolar disorder, major depression, and anxiety disorders. These "brain disorders," as NAMI calls them, affect about 5 million people.NAMI's successes -- eight states have already passed legislation requiring insurers to cover these severe mental illnesses on an equal basis with physical illness -- show that we can create sane public policies, as long as definitions are clear and limited.The EEOC cannot undo the much broader language of the Americans with Disabilities Act. But the guidelines focus their examples on a similarly narrow group of biologically based illnesses, with the unfortunate exception of "personality disorders." Psychiatrists have already objected that "bending the rules" for employees with these behavioral disorders, who need to learn discipline and self-control, will only worsen their problems.But nothing in the EEOC guidelines -- mocked in The New York Times with headings like "Reckless Chauffeur," "Loud Librarian," and "Medicated Saw Operator" -- requires employers to tolerate inferior performance or disruptive behavior. Work schedule adjustments are clearly intended to give people with biologically-based illnesses time to seek treatment and to adjust to medications, which can create new impairments at first.The guidelines never suggest that episodes of severe mental illness should qualify for sick leave, although they already do in many companies. Even an unpaid emergency psychiatric leave can be denied if the business can show undue hardship -- unlike federally mandated leaves for pregnancy and for illness of a family member.Clearly the guidelines do not require that mental disabilities be treated like physical disabilities. And compared to the capital costs of accommodating physical disabilities under ADA -- ramps and elevators, wheel-chair accessible bathrooms and drinking fountains-- they ask for little more than understanding and reasonable flexibility.Why, then, have the guidelines stirred up such a fuss? Far fromcreating a new epidemic, they should reduce the number of "mental disability" complaints --now nearly one in eight of all discrimination cases before the EEOC. But by focusing on people who suffer from the severest mental illnesses, they seem to have conjured up old images of "madness" -- dangerous, incurable -- that still run deep in American culture, even in this new age of biological psychiatry.The fact is that major depression, manic-depressive illness and schizophrenia are utterly different from garden-variety "disorders." Without effective treatment, they can destroy careers, families and lives. People die of them.For those lucky enough to have escaped or survived the worst consequences of these illnesses, the EEOC guidelines afford modest protection from discrimination based on old prejudices. But many have been so severely disabled by their illnesses that a stable job seems like an impossible dream. They cycle in and out of psychiatric emergency wards, often ending up in the streets or in jail. Or they languish in residential care facilities, confined by chemical straitjackets.These people need more than tolerance, they need effective psychiatric treatment and a coordinated network of supportive services in their communities. Often they need asylum, in the best sense of that term -- a haven, a secure retreat.Banishing words like "insanity" has made it too easy to forget the special needs of those the old "asylums" once sheltered. These people are the forgotten casualties of decades of efforts to normalize mental illness in America.