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When mental health becomes an economic issue (and what to do about it…)

Crazy for Comfort

During the last Great Depression, financially desperate people ended up entering convents, seminaries, prisons and mental hospitals, when homeless shelters had no room for them. If the goal was three “hots and a cot,” being admitted to an insane asylum allowed you to eat well, sleep off the streets, and get free medical care. And most of those admitted didn’t have to feign their afflictions…being homeless remains an extremely stressful life circumstance.

Pushed Off the Tightrope, but Ignoring the Net

Social security “safety nets,” put in place by F.D.R., have changed some of the options available when facing difficult economic times, especially for those with psychological disorders. We now have Social Security Insurance, (SSI) for the truly impoverished and disabled among us, and Social Security Disability Insurance (SSDI), an economic survival option for the previously employed working- or middle-classes.

The challenge today is to learn how to identify the need for and to accept help with emotional problems quickly, and to recognize that not doing so could mean taking an economic as well as psychological hit.

You do not need a long history of hospitalizations to qualify for SSDI, and this fact surprises many. ”Extreme” impairment is not a requirement, either.

Mental distress impacts earning potential, and getting help in a timely way is economically as well as emotionally smart. A colleague of mine said she expected most of her clients to improve their earning capacity as a logical outcome of working with her.

Disability Payments You’ve Been Paying For All Your Working Life

But if despite your best efforts, your emotional well-being deteriorates, you need a licensed provider to help you document the type of help you’ve been getting, and the “functional impairment” that requires you to tap into the existing economic insurance policy you’ve been paying 8.4% of your income, (perhaps as much as $9000. a year for…) all of your working life. That insurance policy is SSDI.

And time is of the essence, because you’ll need financial resources to wait it out. SSDI payments often kick in 2-4 years after you’ve apply, but the payments back-date from the time of the initial application. For many, this means getting a check for between $15,000-$20,000, even after all expenses are paid. That can truly ease the pain of mental distress. And your benefits will continue until your retirement, as long as your impairment continues to be documented, typically every 3-5 years.

Knowing Your Options

This post is about knowing your options. My readership is a group that by and large values financial independence, and has a deep distrust for all things governmental. But they also plan for the worst, and are deeply pragmatic. The “sin qua non” of mental health is often the capacity to sort out reality from illusion, figure out who to trust and who to be suspicious of, and determine ahead of time actions that will help you, from those that can prove more damaging.

So here is information to tuck away in case you ever need it.

Overview

I’ll begin by discussing the differences between SSI and SSDI, and the related increase in both unemployment and disability claims. I’ll go on to describe the professional players (lawyers & psychologists) who usually assist people in filing these mental health insurance claims, and provide an overview the required steps to document a “functional mental impairment.” Next, I’ll looks at different social and economic attitudes of those applying for SSDI vs. SSI, and the impact it has on their overall financial well-being. My work in the inner city over the last three years helping clients get SSI will inform this discussion.

I will end by arguing that those in the working- and middle-classes are often the most reluctant to seek psychological care when they develop functional emotional problems that impact their working life. This is unwise, not only from a social and emotional perspective, but also from a financial one. No one with a work history and financial assets should impoverish themselves before seeking government assistance, because you have directly paid into these funds through FICA contributions, and these funds are designed to buffer you from this very situation.

Unlike the urban poor, who use government monies as a baseline income, the middle classes errs in the opposite direction. They refuse available resources, and instead spend down their savings and retirement. Their invisible illness often negatively impacts their professional relationships. Only in desperation, when all other resources are exhausted, do they consider what has been available to them all along.

Had they been more pro-active, and known their options, they might have prevented the catastrophic hit. I provide a story of one entrepreneurial family who prevented financial ruin as an example of how this can be done.

What is SSI and SSDI?

Social Security is a federal insurance plan that pays for someone’s “total disability” including mental health impairment. “Disability” under Social Security, is based on your inability to engage in consistent productive work. The difference between SSI and SSDI, is in who pays for it, and whether the applicant has “resources” (e.g. cash, a home, cars, or investment accounts) or not.

Resources and Who Pays

Think of SSDI as ‘Worker’s Disability.’ Paid out of the Social Security trust fund, it is available to those who have worked and paid 4.2% (or 8.4% for the self-employed) included in FICA taxes, for a required minimum number of years. The amount of SSDI payout, is linked to your employment history, is paid out of workers’ tax contributions. Eligibility does not take into account one’s assets. Owning assets does not affect your eligibility for Social Security Disability Insurance (SSDI).

SSI, on the other hand, is a need-based program for people with low income and few resources. Individuals can apply for SSI if they aren’t insured for SSDI, or are insured for SSDI but are only eligible to receive a fairly small SSDI monthly benefit. A person may potentially be eligible to receive both SSDI and SSI. This is known as a “concurrent disability claim.” Currently, the cap on assets for SSI is set at $2,000 (or $3,000 for a couple). But some assets, like the house you live in and the car you drive for basic transportation, aren’t counted toward the cap on assets.

Substantial Gainful Activity
Being “disabled” means being financially, as well as physically or mentally disabled. ”Substantial Gainful Activity” is work that monthly brings in over a certain amount of income. The amount changes year to year. Make more than that amount per month, and SSA says you “are able to engage in competitive employment in the national economy.”

Disability Rises with Unemployment

Here is a chart that shows REAL unemployment statistics, courtesy of Shadow Statistics:

Now let’s look at the rise in disability:


Rise Seen in Social Security SSID Benefit Lawsuits

Appeals Tell the Tale

According to the Transactional Records Access Clearinghouse (27 Jul 2012):

“…the latest available data from the federal courts show that in June of this year there were 860 new SSID (not a typo) Title XVI lawsuits filed, most under US Code Title 45 Section 405 which allows for judicial review when Social Security supplemental security income (SSI) benefits are denied. The number of filings for each of the last four months (March through June 2012) is higher than for any other month in the past five years. Overall, the data show these filings are up 19.4 percent from a year ago and up 62.6 percent from levels reported in June 2007.” (emphasis added)

These are tough times. And how does that compare to pre-2007 numbers?

Social Security claims that “the share of the U.S. population receiving Social Security Disability Insurance (DI) benefits has risen rapidly over the past two decades, from 2.2 percent of adults age 25 to 64 in 1985 to 4.1 percent in 2005.”

Three in 10 workers between the ages of 18-64 will be disabled, according to SSA.

Why Are Lawyers Involved?

Disability is a steady stream of income for lawyers, who are able to collect up to 25% of all back-payments owed to the filer, starting from the date of first filing, should they win the claim, with a cap of $6000. That adds up to considerable money, as lawyers can handle quite a few claims at one time. The lawyer charges nothing up front to the disabled person, so the cost of entry is low. And attorneys who do nothing but disability cases know how to approach the claim, to maximize the odds that their clients win these claims. They will usually aim for winning 80-95% of the cases they take, so if they take your case, you probably have a solid chance of getting disability.

Therefore, charting SSID, or law suits arguing for disability clients (SSI), is a quick and accurate feedback mechanism for charting the rise of SSI filings.

What Do Psychologists and Other Mental Health Professionals Do?

In the case of those who are filing for mental impairment, they typically fall into those qualifying for SSI, and those qualifying for SSDI. In the agency I worked for, we only took SSI cases, because we only accepted publicly funded insurance.

Those aiming for SSDI will typically want to hire a private diagnostician, rather than go to a public mental health clinic (although many public health clinics take all types of insurance). You want to ask them “How many workman’s comp and SSDI/SSI assessments do you do a year, and do you measure your success rate?” In my agency, we seldom had a client who was ultimately found ineligible (but that may also be due to the multi-problem families we worked with.) I believe there was one in the three years I was there, and that case was currently on appeal.

What to Expect from the Psychologist

Psychologists conduct an interview, and perform a diagnostic assessment. This provides the Social Security Administration (SSA) with psychological testing, such as IQ tests, Projective or neuropsychological instruments, to document the nature and extent of the functional impairment. It is best if the psychologist conducting the evaluation is not the same professional who is treating you on an ongoing basis. Many psychologists do nothing but these types of assessments to be used in disability cases. They know how to write an effective report that meets SSA requirements. A comprehensive psychological report, which clarifies the current diagnosis, and documents functional impairment is required to make a clear case determination.

There are nine diagnostic categories that qualify a person for disability because of mental impairment: Organic mental disorders (12.02); schizophrenic, paranoid and other psychotic disorders (12.03); affective disorders (12.04); mental retardation (12.05); anxiety-related disorders (12.06); somatoform disorders (12.07); personality disorders (12.08); substance addiction disorders (12.09); and autistic disorder and other pervasive developmental disorders (12.10). Each of these, with the exception of mental retardation and substance addiction disorders, requires both a statement describing the disorder(s), including a set of medical findings such as those diagnostic tests given by the psychologist, and a set of impairment-related functional limitations.

SSI Recipients in ‘Deep Poverty’

The case I’m presenting below isn’t an actual person, but it is a composite description of hundreds of families very similar to Ms. James’, that I supervised over my three years working in the inner city with those in deep poverty. We classify families as living in “deep poverty” if they have three elements: (a) severe poverty – an income less than half the median income for poor families; (b) long term poverty – being poor for 5 years or longer; and (c) concentrated poverty – living in a neighborhood in which 30% of families are poor (Wilson, 2005):

Ruby James, (26 years old), has been out of work for 6 years. She is intelligent, but functionally illiterate and probably has an undiagnosed learning disability. Her children, ages 2, 5 and 7, are all on social security disability (SSI) for various reasons including Attention Deficit Hyperactivity Disorder, Autism, and physical disability. Each child has a different father. The oldest child’s father, Mr. Clarke is drug addicted, and there is a restraining order against him by Ms. James for domestic violence. The whereabouts of her second child’s father is unknown. The youngest child’s father is in prison.

Ms. James is currently fighting with her mother over custody of her three children. Her mother, Ms. Thompson, has charged that her daughter is an “unfit parent,” as she alleges that there is no food in the house, and that her daughter is once again living with her former partner and father of her oldest child, Mr. Clarke. She further alleges that her daughter sometimes leave the children home at night alone, “to party with friends,” claiming that the 7 year old is left to “babysit.”

Ms. James denies living with Mr. Clarke. She admits that she is clinically depressed, (the basis of her own current disability claim). She is, according to her own report “a caring and devoted mother.” Ms. James counter-alleges that her mother is fighting for custody of her children “only to get their benefits.”

Ms. James’ children’s benefits, in addition to her aid to dependent children, food stamps, public health care, and subsidized housing costs, are her only sources of income.

All-Out War on Black and Hispanic Men

Her boyfriend, Mr. Clarke, is not working, and if he is living with her, he is another drain on an otherwise overtaxed family system. I was left convinced after my three years working in the inner city, that there is an all-out war against Black and Hispanic men in this country. The education they get in this city is abysmal, and the pressure to stay safe by joining gangs is enormous. The availability of decent jobs is negligible. When they could be found, they were often secured by others through nepotism or outright prejudice. Often, the inner-city applicant lacked even the most basic of job skills. As a result, the intact family, where the father is present, caring, and not abusive, is exceptionally rare in this clinic population. Fathers are essentially absent, abusive, or imprisoned. That is the norm. And it convinced me that families need two loving parents.

Domestic Violence a “Bad Reason” to Land in Prison

Ongoing domestic violence is also quite possible, as her mother alleges, and witnessing that violence puts her children, as well as Ms. James, at risk. Women in these communities expect adult men to spend at least some time in prison. Children visit family members in prisons from a young age. Domestic violence, however, is considered a ‘bad reason’ to be there, although it is often tolerated in the relationship. Children also witness violent murders commonly, and attend funerals of loved ones they’ve lost.

It is the traumatic norm.

Ms. James may also be correct that her mother could indeed have complicated reasons, including financial motives, for wanting custody. She’s raising several other grandchildren, is herself on SSI, and feels she “has the time” and greater “skill” to raise her daughters’ children.

A Seriously Broken System Turns Children into Economic Assets

Conservatives rail against this type of social benefit payout, and it has become “politically incorrect” to paint such a dreary portrait of the lives of those living in “deep poverty.” There is no question in my mind that the system is seriously broken, and serves no one well, including the infrastructure of service providers and state workers that now do home-based services. It is a multi-generational problem that needs multi-generational intervention. In a down-turning economy, this help is unlikely to be forthcoming. What we see in this “Culture of SSI” is that this insurance becomes seen as a sole avenue for financial stability, and given how meager this allotment is, families fight over children who have SSI, as valuable economic resources.

Be that as it may, in a time of increasing economic turmoil, and rising costs of living, the inner city is becoming a nastier place to live, and a tough place to work for those charged with helping families like the James’. In my last year at this agency, I saw many more incidents of violence or threats of violence toward clinicians than in any other previous year.

Middle-Class Disability

Regularly, I was asked to review psychological testing reports and co-sign paperwork for those being evaluated for mental health disability.

I have come to realize that in contrast to the “Culture of SSI” as a foundation of economic security among the urban poor, many working-class and middle-class families in trouble have no idea how SSDI works, or that they might be eligible for it. There is larger stigma about seeking out mental health services among the working and middle classes than among those in ‘deep poverty.’ This could be a financial mistake.

Those who actively seek treatment when in distress, even if only periodically, create a ‘paper trail,’ which enables them to easily accumulate all of the necessary documentation, should a ‘marked’ impairment in cognitive or psychological functioning arise. Those who are more economically successful, better educated, or have a prior history of unbroken prosperity often wait before they get help.

Take this hypothetical case example:

Ralph Albertson, and his wife, have run a small business from their home successfully for many years. However, during the economic downturn, they were unable to sustain it at a viable level. The couple began first to live off their savings, and finally their retirement income, hoping the economy would “turn around.” The impact to his suffering business took a severe toll on Ralph. He became clinically depressed, and at the urging of his wife, was treated by a psychologist, and referred to a psychiatrist for medication. Despite these interventions, Ralph never fully recovered his capacity to work.

He filed for SSDI.

In order to qualify, he was referred by his treating psychologist to a colleague, who gave Ralph six common psychological tests. His psychologist helped Ralph get his paperwork in order, and contact a disability attorney. Ralph was referred to an attorney, because he was self-employed, and these cases can sometimes be difficult to win. Ralph was granted SSDI, after a long waiting period, and two appeals.

The Social Security Administration (SSA) denies 65 percent of the initial claims filed, and appeals are the norm. It also can take a long time to go through the system, on average two to four years.

This application and income, although not a large amount to the Albertsons, cleared the way to other benefits, such as state offered health insurance, food stamps (SNAP) and fuel assistance, that the Albertsons might not otherwise have been aware they were eligible for.

What does “residual impairment” mean to Ralph, who works in his own business from home?

While Ralph is able to continue working in his business, even after receiving SSDI, and the couple continues to receive monthly income from it, Ralph is no longer as effective as he used to be. Once a capable trouble-shooter of customer complaints, for example, Ralph no longer has the “patience” to cope with these calls. He has had to hire part-time help.

While he has “good periods” where he is feeling hopeful and effective, these are punctuated by deeply depressed mood, where he “talks incessantly about economic, environmental, and energy declines that are”, in his words “sweeping the country,” according to his wife. When he’s better, he’s a tireless worker in his community in the Transition Town movement. When he’s not doing well, he barely functions. During these dark periods, he works actively to manage suicidal thoughts, with the help of his therapist.

How Long Does SSDI or SSI Last?

Ralph is 47. At this age, if he continues to be eligible, he will receive SSDI benefits until his retirement. The Albertsons would prefer to be off of SSDI payments, and have a successful business once again. But Ralph and his wife have found out what many poor recipients have discovered: the jump in their income must be quite substantial, if they are to maintain their current ‘subsidized’ lifestyle. This is no easy task in this economy.

Simple, Sustainable Living

The Albertson’s lifestyle is by no means a lavish one. Most would not even call it a “comfortable” income, but the Albertsons have paid off their modest home many years ago, insulated it well in preparation for tough times, cook from scratch, and for environmental reasons, are not avid consumers or intentional tourists. They even have a wood stove, and harvest their own firewood.

Vacillating Functioning

This modest, lower-stress existence has helped Ralph enormously. When his mood, concentration, and attention improves, he is able to work effectively at his desk, and accomplish his work. He will engage easily in meal preparation and housekeeping during these times.

Consistency of Functioning a Key Consideration

These periods of better functioning are not a problem for SSDI, however, because these improvements are not consistent. Consistency in “residual functional capacity” (RFC) is important, to prevent his depression from impacting his ability to do “substantial gainful activity” (SGA). Without his wife and part-time help as back-up, the business would not continue to function, and this has been made clear to SSA.

He demonstrates that need for continued assistance by faithfully attending his therapy appointments, despite these emotional ups and downs. His psychologist is able to give accurate and competent documentation that attests to his need for continued disability payments, when his review comes up every 3-5 years.

“Marked” vs “Extreme” Impairment

Ralph is not a severely impaired individual who is regularly hospitalized for his condition. Social Security Adminstration is clear that this is not a requirement:

“Where we use “marked” as a standard for measuring the degree of limitation, it means more than moderate but less than extreme. A marked limitation may arise when several activities or functions are impaired, or even when only one is impaired, as long as the degree of limitation is such as to interfere seriously with your ability to function independently, appropriately, effectively, and on a sustained basis. See §§ 404.1520a and 416.920a.”

They continue:

“We do not define “marked” by a specific number of different behaviors in which social functioning is impaired, but by the nature and overall degree of interference with function. For example, if you are highly antagonistic, uncooperative, or hostile but are tolerated by local storekeepers, we may nevertheless find that you have a marked limitation in social functioning because that behavior is not acceptable in other social contexts.”

Stopping the Downward Economic and Psychological Slide

If Ralph’s situation doesn’t sound serious to you, if you feel he is “bilking the system” for benefits, it is likely that your own idea of living in hard economic times is accompanied by an elevated tolerance for depressive symptoms as an “acceptable reality of modern life.” Clearly there is a correlation between depression and stress, as there is between unemployment and increased alcohol consumption. But clinical depression is not the same as feeling “bummed out” or “blue” about a loss of income.

Stop-Gap Answer for an Ongoing, Deteriorating Economic Climate

The question remains how many of us would be as pro-active as the Albertsons and take the steps necessary to contact a professional and seek help in a similar situation? And how many psychotherapists would be familiar enough with the SSDI process, or integrate the necessity of economic help, as part of their treatment plan? In Ralph’s case, that help was not totally successful in alleviating his symptoms, to enable him to return to his previous high-level functioning. If it did, he might have found other ways to generate income for his family, even in these financially challenging times.

However, his lingering depressive symptoms, which impact his capacity to function in this present hostile economic environment, prompted his psychologist to encourage Ralph to consider SSDI, as a stop-gap measure to alleviate his family’s ongoing and deteriorating economic condition. And SSDI was successful in helping Ralph to keep his home, as well as his sanity, intact.

The Shame of Reaching Out

Ralph had steadily paid into FICA, 8.4% of his income, once he became self-employed. Still, it took supportive counseling before Ralph could see that it was the economy, not his entrepreneurial skills, that were failing, and to accept depression as a diagnosable mental disorder, not a personal weakness.

SSDI now serves as a financial support, partially restoring the steady income that both the economy and Ralph’s depression has taken away from him.

Unwillingness to Accept Crippling Emotional Distress

In fact, one might argue that the Albertsons have actually adjusted quite well to their circumstances, by being unwilling to accept Ralph’s depressive symptoms as a “normal” reaction to economic hard times. And there are many indications of this intelligent adjustment to difficult circumstances:

  • Ralph is still happily married;
  • He’s resisted the lure of abusing drugs or alcohol to cope with his depression, and;
  • He has maintained his community contacts.

He should be applauded for being pro-active.

If we were to ask him what he thought of this experience, he might say something like this:

I wouldn’t recommend depression to anyone. I felt so terrible, I wanted to die to stop it. I can’t see anything positive in my life, past or present, including my wife, when I’m depressed, and I used to take it out on her, but I’ve learned how not to.

She was the one that insisted that I get help. I was resistant because it was the worst possible time to shell out money for something I’d always considered a waste of time and money I was also ashamed of what I considered a personal failure, and the last thing I wanted to do was talk to someone about it. But now I’m glad I did. If I hadn’t, I would have continued like that for… I don’t know how long, and eventually our savings would be gone and we’d have to sell our house. And I’d keep telling myself to “snap out of it,” but I never would. I couldn’t on my own.

I know it sounds bad, but I have more freedom now to live my life in a more normal way. I can respond to the pressures more realistically now, and take a break when I need it. There are some days I sit in the sun or take a long walk, rather than sit in the office, because I that’s all I can do, and I don’t beat myself up over it anymore. And the chuck of money, over $18,000 when it finally came through, after the lawyer was paid, really came in handy.”

Forward Into the Past

There is a time, and many say it is coming soon, when families like the Albertson’s will have no other recourse but to sell their house and remain as destitute as any family once found roaming the country during the 1930′s in search of work, with their possessions loaded onto their station wagon.

But that time is not now.

If you, or someone you know is suffering… is just not getting through the day without enormous effort, encourage them to get them help, and keep careful records, when they do. If their functioning is impacted in a marked and prolonged way, consider disability as a financial, as well as a therapeutic option.

The financial life you save might be your own.

What do you think? Leave a comment below.

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