Subjectivity and Ambiguity of Mental Disability Evaluation

Mental Impairments

Decisionmaking problems which are troubling and unavoidable in the adjudication of physical disability claims are of even greater consequence in the evaluation of mental disability. Early recognition of the differences between the two was reflected in the 1938 Social Security Board's conclusion that mental disability "should be excluded" from any SSA program "because it would be too hard to determine" (Stone, 1984, p. 72). The very existence of mental "illness," of course, has been questioned on theoretical grounds (Szasz, 1974). Less theoretically, DDS psychiatrists, clinical psychologists, and examiners who see themselves as responsible for dispensing tax dollars more often expect the mentally disabled to "try" to work. This especially seems to be the case when the disability includes alcoholism or drug addiction, which many doctors and examiners simply do not think should be a consideration despite guidelines to the contrary. The fact that people are stigmatized more by mental impairments than by physical ones (Tringo, 1970) may reduce the sympathy that often makes the adjudicatory difference in close cases. In general, "habits of thought and policies derived from medical care often have different results when applied to mental health services" (Buck, 1982, p. 219.

Examiner-Doctor Interaction

To a greater extent than is the case for physical impairment, clinical experts routinely disagree about the diagnosis, treatment, and prognosis of mental disorders. Such disagreement affects the extent to which DDS psychiatrists and psychologists conclude that a particular claimant meets the listings (Rubenstein, 1985). However, although the evaluation of mental disability is much more subjective than the official ideology acknowledges, this subjectivity is obscured by the same combination of bureaucratic papershuffling, reassuring checklists, and agency jargon that is used with somewhat more justification for physical impairment. Just as in the case of physical disability, where the examiner is handed a doctor's RFC form specifying whether the impairment allows heavy, medium, light, or sedentary work, in mental disability claims the examiner also receives an RFC form where job-related mental activities are rated as markedly, moderately, or not significantly limited. Two important distinctions must be made, though.

For one thing, there is no vocational grid to help the examiner apply the appropriate vocational factors. There are, in fact, no universally recognized "appropriate" factors at all. Age, education, and work history are simply not that relevant to a mentally impaired individual's ability to work (Rubenstein, 1985). Consequently, the examiner must work with ambiguous, poorly defined vocational factors, a frustrating task at best. Inexperienced or uninterested examiners can muddle through this task simply by going along with whatever decision the psychiatrist or psychologist is hinting at--if the hint can be understood.

Unfortunately, unlike the case for physical disabilities, experienced and concerned examiners often are not much better off than inexperienced ones because of the second factor: examiners' poor understanding of mental disability. Examiners generally receive much more training in the physical listings and the vocational grid than in the mental listings. Although an experienced examiner often understands when the doctor has misread a blood test result or overlooked relevant reports, he or she generally has no idea at all what the psychiatrist or psychologist has taken--or is supposed to take--into account, and thus has little basis to question the mental impairment rating or RFC. As a consequence, the final decision reflects the doctor's influence much more than does a comparable physical disability decision. Considering the greater subjectivity and ambiguity of mental disability evaluation, the result of the disparity for the claimant is that the often liberalizing impact of sympathetic examiners is lessened as the case essentially is resolved by one person rather than by two.

The Special Problems of the Mentally Disordered

A different set of problems relects the way in which mental disorder affects claimants' pursuit of their claims. Stuve (1986), after interviewing mental health and SSA workers, noted:

The very disability which entitles the CMI [Chronically Mentally Ill] to benefits also makes it very difficult for them to go through the steps necessary to obtain these benefits. The CMI generally lack social skills, are easily confused and frustrated, and can become anxious and frightened in new situations when they are without their normal supports. The SSA process requires them to effectively communicate their disability, to deal with a confusing and frustrating system, and to do this on the SSA's home field--without many of their normal supports. Is it any wonder that the stress of going through this process causes some CMI to simply abandon the process? (pp. 1-2).

Stuve pointed out that even getting to the SSA office to file a claim is difficult for mentally impaired individuals, who may not have family or friends to rely upon. Once there, "receptionists have discouraged some CMI from applying because their disability is not readily visible. The applications are long and confusing, and the CMI are unable to complete them on their own" (p. 4). "There were complaints that applicants are often required to sign blank release forms, without any knowledge of where these forms would be sent. This can be a problem for the paranoid applicant" (p. 4). Correspondence from SSA or the state DDS is often "very difficult for the CMI to understand" (p. 9). "Some CMI refuse to go see doctors, forget to show up for appointments, and/or are uncooperative with the consulting [medical] examiner".

Complicating matters, many mentally impaired claimants apply for benefits alleging physical rather than mental disability. They "may exaggerate work skills and job history in an attempt to appear 'normal'" and may "simply refuse to admit to a disability" (Stuve, 1986, p. 5). Adding to the DDS burden, many therapists do not submit complete reports, reflecting both the low fees paid for time-consuming written evaluations and the all-too-common view that "it is therapeutically harmful for a patient to be labeled as sick. . . . As one disability rights advocate has said, 'Psychiatrists are astonishingly insensitive to the therapeutic benefits of having an income'" (in Stone, 1984, p. 223, footnote 22).

When the initial claim is denied, mentally disabled claimants "will need someone to help them through [the] appeals process. Even with help, many will find the appeal frustrating and anxiety provoking. . . . Some will simply give up and quit" (Stuve, 1986, p. 6). In a typical year, DDSs deny about two-thirds of all disability claims and even more reconsiderations. At the hearing level, however, "semiindependent" administrative law judges (ALJs) reverse DDS denials over 60 percent of the time(GAO, 1989a). Of the large minority whose denials are affirmed by the ALJs, the SSA Appeals Council unsurprisingly affirms nine out of ten. But claimants who follow through to federal district court receive allowances more than a third of the time. Stone (1984), discussing the better-than-even odds of getting initial denials reversed further down the claims process, noted that "if individuals appeal their cases, if they push against the boundaries with any energy at all, they stand a reasonable chance of getting through" (p. 161; see also Taibi, 1990). Mashaw (1983) pointed out that this "perseverence bounty," though important for those who attain it, "disadvantages the ignorant, the incompetent, and the demoralized" (p. 138). The mentally disordered are at least equally disadvantaged.

Recent Improvements and the Bureaucratic Response

Adopted by Congress in response to widespread criticism of Administration efforts to cut the disability rolls, the 1984 Disability Amendments altered the rationale and specifics of the mental impairment listings and of DDS procedures for a three-year trial period ending in August, 1988. The changes were designed, in part, to increase the focus on work-related functional limitations and to move away from a reliance on one-shot evaluation of symptoms (Novack, 1987; Rubenstein, 1985; see also Collins & Erfle, 1985). The new emphasis grew out of a work group that consisted of representatives of SSA, the American Psychological Association, the American Psychiatric Association, the National Institute of Mental Health, the Mental Health Law Project, and others. Preliminary reports indicate that the new listings have indeed resulted in more allowances (Office of Assessment, 1987), and they generally are considered by advocates and practitioners to be a theoretical advance in the notion of mental disability (Novack, 1987; Rubenstein, 1985). In practice, however, they have not eliminated existing difficulties related to ambiguity, inconsistency, and bureaucratic power imbalances. The new approach, in fact, may have compounded these problems, particularly in view of SSA's grudging acceptance of the changes.

From my position as a DDS examiner, it seemed as if the new rules were often vague, the training inadequate, and the workloads unmanageable. Examiners, agency doctors, supervisors, and managers reacted in widely differing ways, clearly affecting case outcomes. The fate of an individual's claim increasingly seemed to depend on the particular examiner or doctor to whom it was assigned. Although not all DDS offices were affected to the same degree, many of these conditions were fairly widespread, particularly in more urbanized states. According to the General Accounting Office (GAO),

Examiners and DDS officials said that, because of increased emphasis on functional documentation and extensive forms to be filled out, the processing time for mental impairment cases under the new criteria was twice as great as for other disability cases. Their individual caseloads were running about 135 to 150 cases, they said, although they considered less than 100 to be a workable level. SSA has not established goals for pending case workloads. (1986, p. 14)

The GAO (1987) later reported that despite improvements in timeliness of SSA retirement claims, disability claims were taking longer to adjudicate that previously, a situation that has since worsened (Delfico, 1992). The delays apparently reflected, first, the chaos of the early Reagan-era mass benefit terminations; second, the initial impact of the new mental impairment listings; and third, continuing budget constraints and--significantly--continuing disagreement over how to evaluate disability (Delfico, 1992).

An internal SSA report (Office of Assessment, 1987) indicated significant problems with the bureaucratic response to the new listings. In general, although the national allowance rate was up, "substantial changes . . . occurred on the DDS level" (p. 3). In Massachusetts, the FY 1985 mental disability allowance rate of 58.5 percent rose to 73.7 percent in the last half of 1986. In Pennsylvania, by contrast, the initial 54.3 percent allowance rate actually dropped to 38.7 percent. "The wide fluctuations suggest that DDSs were not consistently applying the revised criteria" (p. 3). Moreover, DDS accuracy was found to be lower than previously. Significantly, "the decrease in accuracy is substantial among DDS mental disorder decisions which are unfavorable to the claimant" (p. 10). Despite these findings, however, within the SSA branch directly responsible for the disability program, inaccurate allowances resulting from alleged "overdevelopment" are seen as the problem, not inaccurate denials. SSA policymakers sought to lower the Massachusetts allowance rate rather than raise the Pennsylvania rate.

The purpose of focusing on work-related functional limitations in the new listings was to make it easier to allow claims that previously would have been denied. Not surprisingly, given Administration priorities, the mandated effort to broaden eligibility was linked to increasingly extensive case development and to a qualitatively different kind of file documentation. Unfortunately, these were changes that many examiners were poorly trained to handle and often resented. For example, examiners were uncomfortable with the new requirement to interview mentally impaired claimants or their relatives on the telephone in order to get a detailed description of daily activities and functional limitations. This task often seemed insurmountable to bureaucrats untrained in mental disorder, in intensive interviewing, or in detailed report writing. It was at first often simply ignored as caseloads expanded dramatically.

When the rules were further liberalized to make it possible to allow claims when the only impairment was alcoholism or drug addiction, the workload and resentment rose even more. Efforts in some states to solicit claims from mentally disordered homeless individuals added to the frustration, as homeless claimants were difficult to contact and often could provide little information about their medical history. Even examiners and doctors who were in agreement with the liberalized criteria became bogged down in mounting piles of folders. Despite resignations, a job freeze prevented hiring enough new examiners. More than a year after the implementation of the new listings, amid rumors of impending layoffs and vastly increased caseloads, a resolution was introduced in Congress "instructing the Social Security Administration not to increase the caseload of SSDI examiners or reduce the staff in state disability determination offices to levels that would prevent thorough, adequate case development" ("State Agencies," 1987).

Since the examiner decides how often to try to contact claimants, to reschedule missed exams, to write activities of daily living reports, and so on, a particular case outcome is strongly affected by the examiner's interest in pursuing it. Not surprisingly, many examiners, keeping in mind the quantitative nature of supervisory evaluations of their work, often are less interested in complete case development than in clearing as many "old" cases as possible. The perceived pressure, thus, despite official agency guidelines, is to deny claimants for failure to attend exams rather than to reschedule them, or to accept without question a doctor's nonlimiting RFC even if the examiner believes that more development will demonstrate that the claimant cannot work. Similarly, the primary concern of agency doctors sometimes seems to be to avoid being found "in error" by Quality Assurance. This, too, often results either in long delays in an effort to tie up all conceivable loose ends, or in denials that could have been allowances with more flexible case development and less rigid interpretation of the meant-to-be-liberal listings.

Continuing Issues in Disability Evaluation

I have argued thus far that the differences between mental and physical impairments are not sufficiently taken into account by a bureaucratic ideology that insists both kinds of impairment can be evaluated on parallel objective grounds. This ideology conflicts with the greater subjective nature of diagnosing mental disorder. In addition, in the case of mental disability evaluation, the reality of bureaucratic administration raises to a greater magnitude the practical problems that are present to some degree even when evaluating physical impairments.

Referring to disability evaluation in general, Mashaw (1983) pointed out that:

The subtle but powerful management actions that shape the adjudicatory culture--the focus of QA [Quality Assurance] review, the budget for CEs [Consultative Exams], the setting of productivity goals for examiners--have little obvious bearing on the outcome of particular cases, even though they may markedly affect the gross award or denial rates. (p. 187)

My suspicion is that the nature of mental disorder, and of people's knowledge of it and reaction to it, exacerbates such outcome effects significantly, particularly in view of several recurring, interrelated issues about which I will briefly speculate.

Interaction of Bureaucrat and Bureaucracy

For present purposes, the interaction between individual bureaucrats and the larger bureaucracy can be thought of in three ways. First is the truism that the personal traits of individual bureaucrats differ. Although it can seek to hire and mold a particular kind of worker, the bureaucracy cannot eliminate variability in such factors as background, motivation, prejudices, politics, accuracy, analytical ability, and career goals (Mashaw, 1983). The inevitable case outcome effects should be especially strong in the evaluation of mental disability, which forces the observer to bring more of his or her own self to the evaluation process than is true for physical disability. The fact that many claims are reviewed for correctness cannot eliminate this problem, as reviewers similarly vary among themselves.

Second, and conversely, the nature of the bureaucratic situation imposes pressures that affect most of its members in similar ways. The overpowering quality of bureaucratic reality forces those who choose to remain in the system to conform to major system demands despite individual differences (Hummel, 1982). As job demands change in response to higher-level decisions--as, for example, decisions are made to increase or decrease the allowance rate for different categories of disability by enforcing certain rules or suspending others--the bureaucrat has little practical choice but to adapt, regardless of personal inclinations. The power of the situation may have a disproportionate impact on mental disability claims because there are more potentially reasonable ways to evaluate mental disability than is true for physical disability. The ideologically motivated selection of one particular method by policymakers, often in response to political decisions made outside the agency, may thus eliminate plausible alternatives more than is the case for physical disability.

The person and the situation interact in the third category, that of ideological differences concerning the very purpose of evaluating people for disability benefits. Although the bureaucracy decides who is disabled enough not to work, "enough" is neither self-evident nor stable over time. Discussing the origin of disability bureaucracies, for example, Stone (1984) detailed the close connection between disability and the labor market. The early English vagrancy laws, which made it illegal to give money to beggars who could work, were a response to the labor shortage caused by the Black Plague of 1347-49 (Stone, 1984, p. 34). The laws were designed to prevent workers from supporting themselves by begging while travelling in search of higher wages; only those legally recognized as unable to work were allowed to leave town.

With labor surplus rather than labor shortage, the trend in Western Europe "has been to extend eligibility under programs traditionally designed for the retired or the disabled as a way to alleviate unemployment" (Reno & Price, 1985, p. 24). It may not be a coincidence that, in contrast to the United States, "the most consistent trend [in Western Europe] is the apparent ease with which health and social security benefits are provided to those [mentally impaired individuals] who are in need" (Jansen, 1986, p. 1277). Even in the US, where a stricter social security program is conceived of as separate from the unemployment program and there has been resistance to officially linking the two (Reno & Price, 1985), there have been enough exceptions to make the inherent connection inescapeable. SSA's institution of early retirement benefits in 1961, during an economic recession, "was seen as a way to reduce unemployment among older workers. The change was in part a response to long-term technological unemployment, recognizing that persons who lost their jobs at older ages might never find other work" (Reno & Price, 1985, p. 30; see also Taibi, 1990). Similarly, changes in 1979 in SSA's vocational guidelines significantly eased the disability criteria for unskilled workers over age 50, making it possible for more older workers to drop out of the overcrowded work force (Stone, 1984, p. 165). As Stone noted,

When ideology mandates that everyone should work but society cannot provide employment for large segments of its population, the dilemma can be reconciled by defining a higher proportion of the population as disabled. Because disability is the most flexible of the categories of the need-based system, it is the one most readily available for use in this fashion. (p. 168)

The mental disability criteria are especially susceptible to changing economic, political, and professional pressures, as the mass eligibility terminations in the 1980s and the resulting new listings make clear (Rubenstein, 1985).

In addition to official views of where to draw the disability line, individual bureaucrats have their own ideas, which are often at odds with whatever official position is current. Although managers attempt to hire examiners and doctors who are not ideologically committed to stray outside the bounds of DDS acceptability, individual differences among DDS workers are common. This goes beyond personal sympathy for individual claimants seen as particularly deserving, and extends to explicit or implicit ideological positions that the rules are too strict or too lax. Some are perfectly willing to allow mental disability benefits even if the impairment can't be "objectively determined" because of a belief that "this person will never work" and that it doesn't really matter if support comes from SSA or unemployment or welfare, so long as it comes from somewhere. Others are extremely reluctant to allow claims for those who are seen as having "caused their own problems." Mental impairment claims raise these value issues more than do physical impairment claims.

The Inevitable Presence of Inconsistency

In one typical study, the chances of two examiners reaching different decisions on sample cases were one in eight within the same DDS, and one in six for examiners in different DDSs (Stone, 1984, p. 133; see also General Accounting Office, 1987). Although such a level of inconsistency flies in the face of an objective bureaucratic approach, it should not be surprising given the inherently subjective nature of disability adjudication.

The disability decision process has been repeatedly studied and repeatedly criticized for (1) interstate inconsistency in both outputs (award rates) and inputs (use of CEs, for example); (2) dramatic variance between state agency-ALJ and ALJ-court decisionmaking; (3) ineffective QA control; and (4) the structural complexity and delay in the decision process. These same problems have been perceived ever since . . . 1960. Why, in twenty years, haven't some clear remedies emerged?

The answer lies in the elusiveness of accuracy in the DI . . . program. (Mashaw, 1983, p. 195)

Mashaw concluded that, in fact, bureaucratic inconsistency allows professional discretion to counter "a demand for objectivity [which], without changes in the resources devoted to processing, tends to produce stringency" (1983, p. 176). Thus, attempts to eliminate subjectivity reduce the allowance rate. Similarly, Stone (1984) argued that "a system of seemingly firm, objective standards . . . combined with a high degree of discretion on the part of disability determiners helps legislators resolve their ambiguity" (pp. 182-83). In this sense, inconsistency may be a way to enable the system to adapt to changing standards, but at the cost of an unknown number of people falling through the cracks. It might be better to openly acknowledge the subjective nature of disability adjudication--especially in the case of mental disability--and move away from a focus on centralized objective standards that cannot be met even in theory.

Adherence to objective scientific medical diagnosis fails on at least two counts. First, "medical criteria cannot be more objective and scientific than the body of knowledge and practice on which they rely" (Mashaw, 1983, p. 110). Many facts will always remain unknown to doctors and examiners, for reasons ranging from fragmentary medical records and individual differences in interpreting X-ray reports to bureaucratic preferences for certain kinds of information (such as the discounting of evidence submitted by chiropractors, social workers, and other "nonmedical" sources). In the case of mental impairments, where diagnosis is both difficult and subjective, "misdiagnosis is common" (Rubenstein, 1985, p. 720) and can directly affect whether or not a claimant meets the listings. This is doubly significant since, as discussed above, examiners are less able to use vocational factors to find someone disabled who does not meet the listings.

Second, there are individual differences in people's ability to function given the same degree of objective impairment.

That the clinical concept should fail as a restrictive mechanism is not surprising, because in an important way it sidesteps the key issue of disability: what is it that prevents people from working? In most instances, the cause is not some identifiable physical phenomenon but a complex set of interacting factors involving individual and family history, the state of the economy, and cultural and psychological as well as biological factors. . . . Pain, fatigue, shortness of breath--and, one might add, anxiety--are all real and very powerful subjective phenomena, but they defy measurement. (Stone, 1984, p. 134)

Such factors are all the more important--and more difficult to assess--in decisions to work or not to work made by the mentally impaired. The current mental listings do call for a greater focus on actual daily functioning. Still, it would not be surprising to find that agency psychiatrists and psychologists continue to rely more heavily on diagnosis and symptomatology than on laypersons' descriptions of daily functioning, despite abundant evidence that symptomatology and diagnosis bear little relation to the capacity to work (Anthony & Jansen, 1984).

Medicine, Law, and Bureaucracy

The third general issue in disability evaluation has to do with the tension caused by the differing perspectives of doctors, lawyers, and bureaucrats. Mashaw (1983) discussed competing "justice models" within SSA, where bureaucratic rationality, professional treatment, and moral judgment provide clashing approaches to disability adjudication. "The bureaucratic rationality-moral judgment compromise was . . . struck, in part, in the form of a temporal separation--bureaucracy first, followed by individualized hearings for the dissatisfied" (p. 39). In the initial bureaucratic stages, there is a constant interplay between professional medical judgment and the bureaucratic necessity for standardization and consistency, as discussed above. Especially at the appeals levels, however, SSA is under constant judicial pressure to liberalize standards and procedures in accordance with legal, rather than medical or bureaucratic, concepts. SSA continues to resist such efforts, preferring its own interpretations of legislative mandates.

The level of the administrative law judge hearing has drawn the most outside attention (Cofer, 1985, 1987; Mashaw et al., 1978; Parmele, 1987). A central focus has been the appropriate degree of independence of ALJs, who work within SSA's Office of Hearings and Appeals but see themselves as independent. There is a common view within SSA that the ALJs simply "don't follow the rules," that ALJs in particular allow cases without having to justify their decisions the same way that DDS examiners and doctors do. One manager told me that the 50-plus percent reversal rate was a "shameful statistic," and that ALJs as a group, who are "incredibly poorly trained in SSA regulations and medicine," incorrectly "see themselves as members of the judiciary rather than as the administrative personnel they really are."

In contrast to the common SSA view, Cofer (1985) pointed out that ALJs base their decisions on Congressional statutes and judicial precedent rather than on SSA's internal instructions, despite SSA insistence that its own instruction manual presents the correct interpretation. Cofer uncovered several important differences between statutes and SSA guidelines that add to the high reversal rate of DDS denials. Although many ALJs regard the quality of DDS case development as poor, "if the states and ALJs continue to use essentially different standards of judgment, all of the care given to case development will be for naught" (Cofer, 1985, p. 184). This continuing conflict was reflected in a 1983 suit filed by the Association of ALJs against the Secretary of Health and Human Services (HHS) on the grounds that SSA "had directed administrative law judges to ignore court decisions favorable to claimants and had put pressure on them to deny claims" (Liebman, 1985, p. 38).

There are other reasons for the disparity between DDS and ALJ decisionmaking. Perhaps most importantly, Stone (1984) noted, the ALJ sees and talks to the claimant in person, unlike DDS personnel. This allows a focus on the individual's subjective experience rather than on the "average person" approach of the listings. "To 'individualize' a disability determination process in a modern mass society seems incongruous to a bureaucrat; yet a judge will view the bad fortune of an otherwise viable human being" (Cofer, 1985, p. 7). In addition, Stone pointed out that legal and medical notions of causation and proof differ. To oversimplify, the doctor/scientist may allow a claim only if 95 percent certain that the underlying impairment fully causes the inability to work; the lawyer/judge may award benefits if a preponderance, or 50.1 percent, of the evidence shows that the impairment is a contributing cause. Finally, the courts are more likely to interpret the disability program as a contract between the insured and the insurer, a contract "whose provisions are somewhat fuzzy" (Stone, 1984, p. 159) and, thus, to be interpreted liberally, in accordance with public views of disability that are less stringent than the official definition.

Although DDS-ALJ differences are reflected in high overall reversal rates, the conflict is seen even more clearly in cases of mental impairment. After the 1981-82 termination of thousands of disability beneficiaries, appeals to ALJs brought reversal 60 percent of the time. In cases of mental disability, however, the reversal rate was 91 percent (Cofer, 1985, p. 116).

The second relevant aspect of the varying perspectives on disability results from the fact that, although SSA regards the ALJs as too lenient, when ALJs do affirm DDS denials they often are overruled by federal judges who see the ALJs as too tightly linked to SSA. The resulting burden on the courts has led to calls by Supreme Court Justice Antonin Scalia and others to cut down on the "triviality" of federal court cases by establishing specialized Social Security courts (Lauter, 1987). It has also led, not surprisingly, to a large number of private lawyers and nonprofit advocacy groups that provide legal support for claimants who appeal their denials. The National Organization of Social Security Claimants' Representatives publishes a newsletter that informs lawyers of the status of significant legal issues and offers suggestions on how to deal with SSA both in and out of court. Professional legal and advocacy organizations study, and recommend changes in, SSA practices (e.g., "Disability Symposium," 1986; Rubenstein, 1985).

A third related aspect of this general issue is the constant interplay between the courts, which routinely order SSA to modify particular procedures or criteria, and SSA, which often nonacquiesces in rulings with which it disagrees. "The agency complies as to the individual's case but tells its officials, including administrative law judges, to continue applying the policies that reflect the agency's view of the correct legal interpretation" (Liebman, 1985, p. 38). Thus, other claims raising the same issue must each be brought to court individually, adding to the burden on the court, to mutual SSA-ALJ recriminations, and to claimant costs and frustration. When SSA does acquiesce, it often applies the judicial ruling only in the federal district in which the ruling was made, complicating the problem of different DDSs using different rules.

Discussing similar phenomena in the welfare system, Rosenblatt (1982) noted:

The vast majority of decisions are never appealed, not because they are correct, but because the poor lack the information, resources, and advocacy assistance needed to confront the complex welfare bureaucracy. When agency actions are appealed, the resulting decisions do not function as a system of internal control, because no discernible pattern of appellate policy is developed and communicated to the line caseworkers. The result is a system of procedural rights that may help a small number of aggressive or fortunate recipients, but which functions largely as a legitimating symbol of fairness for a generally unchanged system. (pp. 273-274)

Although the appeals levels have forced liberalization of the mental impairment rules, the nature of the process still works against those who do not have the financial resources, stamina, initiative, and forethought that are required to get to court. These qualities remain disproportionately beyond the reach of the mentally disordered.

Directions For Change

Suggestions for helping the disabled to better meet their needs can be placed in four categories: (a) improving the present system, which essentially is accepted on its own terms, primarily through greater managerial control; (b) reforming the system administratively or legislatively by altering particular procedures; (c) abandoning some of the system's basic assumptions; and (d) replacing the system.

Managerial Control

The usual bureaucratic response to problems such as case inconsistency, employee variability, state discrepancies, and high reversal rates is to attempt to improve the methods it is already using. It is assumed within the agency that failures to meet standards "constitutes a problem of implementation, not problems in the concept of impairment itself. Hence, the SSA responds to criticisms of its determination process . . . by providing more training, more guidelines, and more supervision" (Stone, 1984, p. 127)

Some of these efforts are useful. Better examiner training in mental impairments is clearly in order, if only to reduce examiner confusion and frustration and to enhance job satisfaction. More examiners and clerical assistance would also help. The GAO (1987, 1989b, 1989c) repeatedly reports that employee morale is low across SSA and DDSs, partly because of increased workloads and poor advancement prospects resulting from budget cuts and job freezes and partly because of a sense that management insufficiently considers employee welfare during frequent program changes.

SSA eventually may have to consider dividing examiners into those who work on physical impairment claims and those who work on mental impairments, each with different training and, perhaps, different background requirements. Such a split would be organizationally difficult and would complicate the cases of people with multiple impairments. It would, however, be analogous to the decision, made several years after the SSI program began in 1974, to divide district office claims representatives along program lines because of the increasing inability to master simultaneously the growing complexities of both Social Security and SSI.

Despite efforts to smooth the rough edges, "there are important reasons why a concept of disability based on clinical criteria is bound to fail" (Stone, 1984, p. 127) and why there are limits to the level of accuracy that can be achieved. Attempts to enhance bureaucratic control are often counterproductive. As noted above, enforcing consistency by relying on quantifiable criteria can lower the overall allowance rate (Mashaw, 1983). Interest in devising an objective vocational grid for use in mental impairment cases (Rubenstein, 1985) might be an example of what Hummel (1982) called bureaucracy's "tendency . . . to substitute inner control for outward service" (p. 67).

Institutional Reform

Many suggestions have been made to reform components of the disability process, and SSA itself has considered a number of different arrangements. Rather than accepting frequent calls to increase judicial review of the bureaucracy by, for example, making hearings more adversarial, SSA has experimented with such innovations as providing for personal contact between DDS examiners and claimants. After one such trial in 1976 resulted in more allowances, SSA recommended implementing this reform throughout the system, but was overruled by HHS (Mashaw, 1983, p. 198). A similar experiment with a Personal Appearance Demonstration Project was mandated by the 1984 Disability Amendments ("Personal Appearance," 1986), and the GAO has continued to advocate face-to-face meetings between examiners and claimants (Delfico, 1991). At the same time, somewhat paradoxically, SSA has experimented with sending an agency representative to hearings. Although officially not designed to make the hearing adversarial, the practice was halted briefly by a federal judge who "found the government representative experiment to be yet another method of tipping the scales against claimants" ("Unconstitutional," 1986, p. 3).

In addition to calling for more examiner-claimant contact, Mashaw (1983) proposed a system that would provide representation for claimants, not by lawyers ("most of whom do not understand the disability system well enough"--pp. 201-202) but, perhaps, by examiners hired specifically to represent claimants. Mashaw would also move away from increased judicial review in favor of a greater professionalization of the decisionmaking process ("a different unhappy compromise"--p. 203). He suggested giving claimants at the reconsideration level an SSA medical examination performed by a panel of three doctors, or, alternatively, leaving decisions to a comprehensive multiprofessional panel of experts. Both of these options would be expensive, and although they would result in more allowances, they would probably not reduce the "irreducible category of marginal claims that will never be consistently decided" (Mashaw, 1983, p. 206).

Another frequently suggested institutional reform is the abandonment of the joint SSA-DDS system in favor of a centralized system directly run by SSA. Studying the prospects of federalization and of another alternative, privatization through contracting out, the GAO (1985) acknowledged that "the statutory definition of disability is necessarily subjective" (p. 10). Either federalization or contracting out would give SSA greater control "and, in theory, offer greater possibilities of increased uniformity" (p. 3), but the GAO concluded that abandoning the present system would meet with much opposition and would probably neither produce better decisions nor save money. The report called, instead, for a number of managerial steps "to improve administration within the current federal/state arrangement; e.g., SSA could improve the directives and guidelines it provides to the DDSs" (p. 4). Of course, if federalization did result in better decisions according to SSA standards, the cost would be a lower allowance rate, especially in states where the DDSs consider national guidelines to be too stringent.

Abandoning Basic Assumptions

Two broad changes in the basic ideological assumptions upon which SSA is built should be considered, one relating to mental disability in particular, the other more general.

Objective mental disability evaluation

Although the evaluation of claims for physical disability is difficult enough, SSA should explicitly acknowledge that, in contrast to its operating ideology, applying the same kinds of objective criteria to both physical and mental disability is fundamentally misguided. This goes beyond merely acknowledging that the evaluation of mental disability requires more professional judgment than the evaluation of physical disability, and it goes beyond the focus of the new mental listings on functional work-related activity. The new listings, despite their advantages over the old, remain embedded within the medical diagnosis approach, and as such stand opposed to the view that objective medical evaluation intrinsically is incapable of eliminating inequities caused by individual subjectivity and bureaucratic reality. Better training of examiners in how to gather evidence of functional limitations and how to evaluate vocational factors is crucial, but within SSA's operating rationale such vocational analysis remains secondary to the agency psychologist or psychiatrist's rating of medical impairment.

Without doing away with the present approach completely, SSA could strengthen the focus on the claimant's actual ability to function by abandoning the assumption that only a DDS psychiatrist or clinical psychologist can evaluate impairment and that only "medical evidence" provided by an MD or PhD is deemed adequate. Although reports submitted by a claimant's social worker, for example, are now considered by DDS, unless the report is countersigned by a doctor (who may have no continuing interaction with the claimant) the claimant will be required to go to a one-time consultative exam. This insistence on a medical approach prevents the reasonable use of reports submitted by professionals who know the claimant's abilities best. At present, nonmedical reports do affect decisions, but they do not have the weight that they should.

Suggestions have been made to focus more heavily on individualized structured work evaluations in order to better assess vocational capacity (Anthony & Jansen, 1984). While these evaluations are often seen within the agency as potentially useful, they are expensive and time-consuming, and thus rarely used. It is not clear that they add useful information to what is often available from social workers, counselors, and relatives. Of course, as DDSs currently are structured, work evaluation reports are assessed by the psychologist or psychiatrist, and thus do not move away from the medical diagnosis focus. Equally seriously, the objective appearance of such reports masks, but does not change, their subjective nature.

It is not likely that SSA will consider an open abandonment of the medical approach. In fact, it is only since the 1984 Disability Amendments that clinical psychologists have been allowed to evaluate claims without a physician's countersignature (Landers, 1986; Novack, 1987), and it is still too soon to tell how fully they will be integrated into the system. In some DDSs the staff psychologist's job remains primarily the evaluation of psychological test scores--and SSA has suggested reducing the use of psychological tests, a move opposed by APA (Freiberg, 1992). One psychologist told me that agency psychologists, moreso than psychiatrists, find it difficult to rate functional abilities as "markedly" or "moderately" limited, to place claimants in narrow categories. This point is in keeping with speculation about the cognitive effects of training differences between psychologists and psychiatrists (Kingsbury, 1987). Efforts to bring psychologists into SSA on an equal footing with psychiatrists are a step forward for psychology and for claimants, but such efforts may cause psychologists to cling more tightly to the official medical model when the opposite approach is necessary.

Disability and the job market

Both the mentally and the physically disabled would benefit from the abandonment of another fundamental SSA assumption: the insistence that the definition of disability should take place divorced from the realities of the job market. Although there has been some minor erosion of this ideological view, particularly for older workers, much more needs to be done. As is the case in Western Europe, the definition of disability should take into account the reasonable chances that an impaired person will actually be able to find a job when competing for scarce openings with unimpaired individuals. It is grossly unreasonable to deny benefits to someone who might be able to do some kind of limited work but who will never be hired. This basic policy decision disproportionately disadvantages the mentally disordered, who must deal not only with their impairment but also with the accompanying stigma that makes finding work even more unlikely.

Replacing the System

Merely broadening the definition of disability, which necessarily is arbitrary to begin with, can be done within the existing SSA framework. A more far-reaching approach would be to rethink the whole basis for separate disability, unemployment, welfare, and even tort systems (see Abraham & Liebman's, 1993, discussion of "the gaps and overlaps in the existing network of compensation institutions"--p. 77). In a society where there are more people than jobs and where problems of distribution rather than of production interfere with providing basic needs for all, it is not enough to tinker with individual components of the present bureaucratic structure.

Of course, completely doing away with the disability bureaucracy, perhaps by instituting a negative income tax that would guarantee a minimal standard of living, would not be without bureaucratic problems (Mashaw, 1983, pp. 183-185) and is unlikely to be considered seriously in an economically conservative era. Also unlikely in the near future are other progressive developments that would help the partially disabled find appropriate jobs. Because "virtually everyone is capable of doing something productive" (Taibi, 1990, p. 919), the institution of a shorter work week, the creation of meaningful parttime work at higher wages and benefits, and the transition to more cooperative workplaces and more liveable communities might allow many people currently seen as disabled to participate more actively in the society around them. The potential benefits of fundamental social change should not be dismissed solely because such change is not imminent. The degree to which centralized bureaucratic reality is inherently at odds with meeting human needs requires us at least to consider solutions that ultimately go beyond minor reforms (Fox, 1985, 1993; Wineman, 1984).

In the meantime, and without losing sight of broader efforts at change, reforms of SSA's current approach to disability evaluation must continue. The methods used to adjudicate claims for physical disability remain complex and controversial. They are applied inconsistently and are only marginally justified at best. The complexity and inconsistency are increased many times over, and the justification decreased by a similar degree if not lost entirely, when methods based on the same assumptions are used to adjudicate claims for mental disability.

Before the new mental listings went into effect, Rubenstein (1985) noted that "the changes in the standards and procedures . . . are almost complete. They amount to a major and beneficial overhaul. Yet, because of bureaucratic resistance to change, the practical consequences cannot be foreseen" (pp. 722-723). Since then, the consequences support my suspicion that the mismatch between bureaucratic reality and the fundamental nature of mental disorder, even in the conceivable absence of explicit bureaucratic resistance, sharply limits the potentially beneficial impact of the new listings or of any similar reforms. As long as there is a continuation of the "medicalization of social problems" (Stone, 1984, p. 12) and the approach to meeting basic needs remains based on objective medical decisionmaking, mentally disordered people will remain disproportionately disadvantaged.

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