When Do I Disclose?

SUMMARY

The Americans with Disabilities Act of 1990 (ADA) heralded a new era of civil rights for the disabled, including the mentally ill. This article concerns Title I of the ADA, protections against discrimination in employment. It is a revised version of an article orginally published in a consumer publication, the MDSG/New York Newsletter (Mood Disorder Support Group) to provide guidance on the pro's and con's of making disclosure of mental illness in the job environment. As such it is a valuable reference for both therapists and service recipients who wish to learn more about how the ADA relates to the employment of people with mental illness and who may be faced with the difficult decision of whether or not they should disclose their condition and request reasonable accommodation. Occupational therapists should be well-informed on this topic, to assist consumers with questions on disclosure, reasonable accommodations and other aspects of Title T. Employers can benefit by providing them with information about appropriate accommodations. And occupational therapists can advise both consumers and employers on how a psychiatric illness may affect work performance.     

The Rise and Decline of the American Asylum Movement in the 19th Century

This paper traces the history of the American public asylum from the 1840s through the late 19th century. The focus is on social factors that contributed to the establishment of public institutions at the urging of reformers, the attempts to model them on the architecture and “moral treatment” offered by the best private institutions, the crowding of the asylums, the growing criticism aimed at the asylums and their superintendents, and the effects of calls for other approaches and for scientific management. Knowledge of the asylum's history may be useful today, as we stand at the crossroads in the treatment of the mentally ill.     

Research Protections for Diverted Mentally Ill Individuals: Should they be Considered Prisoners?

The number of diversion programs for the mentally ill has increased dramatically over the past decade. These programs serve the valuable goal of reducing the growing population of incarcerated mentally ill persons by providing supervised community treatment. Research within these programs, critical for improving outcomes for these vulnerable individuals, is complicated by the fact that participants may have legal statuses which carry significant coercive leverage. In this way their ability to freely consent to research may be limited. In this paper, the authors describe the practice of diversion and review relevant research on coercion, informed consent and decisional capacity among the mentally ill and imprisoned. Current legal protections for prisoners are then discussed in the light of a recent proposal to broaden the legal definition of “prisoner” for research purposes to include community corrections populations, thus including diverted individuals. Copyright © 2011 John Wiley & Sons, Ltd.     

The Gentleman Vanishes: Dementia,Caretaking and the Life of the Mind

This essay recounts the author’s journey with her father during his prolonged decline due to dementia. The experience pushed her to break out of the confines of conventional scholarly research in her academic field of architectural history to a multi-disciplinary consideration of nineteenth-century environmental, sensory and horticultural therapies for the mentally ill. During her father’s illness, she discovered the tangible therapeutic benefits of momentary engagements with his environment through his five senses and through the emotional filter of poetry. This reorientation to sensory and poetic experience had a beneficial impact on the caretaker as well.     

The rise and decline of the American asylum movement in the 19th century

This paper traces the history of the American public asylum from the 1840s through the late 19th century. The focus is on social factors that contributed to the establishment of public institutions at the urging of reformers, the attempts to model them on the architecture and "moral treatment" offered by the best private institutions, the crowding of the asylums, the growing criticism aimed at the asylums and their superintendents, and the effects of calls for other approaches and for scientific management. Knowledge of the asylum's history may be useful today, as we stand at the crossroads in the treatment of the mentally ill.     

Rotting with their rights on: why the criteria for ending commitment or restraint of liberty need not be the same as the criteria for initiating commitment or restraint of liberty, and how the restraint may sometimes justifiably continue after its prerequisites are no longer satisfied

That coerced treatment must end when the criteria for initiating coerced treatment cease to apply appears to be universally accepted by courts and commentators.2 Moreover, the consensus appears to be justified by a steel-trap argument. If coercion is justified only when the patient is mentally ill and incapable, because then the patient lacks autonomous capacities, or lacks practical reasoning abilities that undercut autonomous capacities, then these justifications have no force when the patient either is not mentally ill or is capable. A parallel claim holds for civil commitment. This received wisdom, or in = out thesis, rests upon a conceptual confusion: a failure to distinguish the criteria for initiation of intervention, those for cessation of intervention, and the purpose of the commitment or coerced treatment. If the criteria for commitment were mental illness and dangerousness, and the criteria for release were the same, then the purpose of commitment would be to restore persons to the point where they are either just barely not mentally ill, or just barely not dangerous. That is a silly and self-defeating purpose for that large class of patients who, because of lack of insight, or otherwise, do not become treatment compliant until they are substantially healthier than being barely not mentally ill or barely not dangerous. It sets them up to become revolving-door patients. The purpose of commitment is rather to maximize the patient's mental health, and minimize her dangerousness without unduly burdening her liberty. If society is going to violate a patient's liberty, it should do so in a way that will resolve the problem that justified the restriction on liberty in the first place, so long as the restriction of liberty is not too great in relation to the expected gains from the intervention. The criteria for releasing a patient from commitment are in this way responsive to the purpose of the commitment. For some revolving-door patients, this entails that the criteria for their release from commitment should be stricter than the criteria for initiating commitment in the first place. The criteria for release from commitment for revolving-door patients should be that the criteria for initiation for commitment is not met plus it being more likely than not that the patient will be treatment compliant after release, assuming the additional restriction on liberty is less than the gains from the additional restraint, and the restriction is not unduly burdensome. Spelling this out, the criteria for release should be either not mentally ill, or else not dangerous, or capable, and more likely than not to be treatment compliant after release. For those patients for whom such a test is overly optimistic, we might substitute that there is a reasonable probability of treatment compliance after release, or that the probability of treatment compliance has been enhanced. These criteria are to be thought of as rough and ready rules of thumb, and not as analytically precise tests.     

Community treatment for the seriously mentally ill: Is this community psychology?

Community treatment for seriously mentally ill individuals fits well into the philosophy of community psychology. Community psychologists have skills and experiences with other populations that represent assets in improving the ACT service model and producing richer and more useful research results for the future. Maybe we should ask ourselves why community psychologists have obviously avoided this intervention area and the population of seriously mentally ill individuals. Does this represent an adolescent reaction to the parent discipline — clinical psychology? Is the label “mentally ill” as stigmatizing to community psychologists as it is to the general population? Are these individuals written off as not worthy of or capable of benefiting from preventive interventions? Advocates for the seriously mentally ill are mounting a backlash against prevention services. We would be well advised at this time to become involved in community treatment and demonstrate that community psychology is forall vulnerable and at-risk population groups. If the truth of the matter is that “community psychology is not doing much of a job of empowering people” (Berkowitz, 1990), maybe the truth of the matter is also that we need to reach out to more disenfranchised populations with research to show that community psychologycan do the job of empowering some.     

TRANSITIONAL EMPLOYMENT FOR THE CHRONICALLY MENTALLY ILL

This article discusses the use of transitional employment in the vocational and psychosocial rehabilitation of the chronically mentally ill. The development and implementation of a transitional employment program at Towne House Creative Living Center, Oakland, California, is described. The value of adapting the work environment and use of support groups in aiding psychosocial and vocational adjustment are discussed. It is concluded that transitional employment is an effective treatment modality that can be utilized by occupational therapists involved in community based treatment of the mentally ill.     

How to justify enforcing a Ulysses contract when Ulysses is competent to refuse

Sometimes the mentally ill have sufficient mental capacity to refuse treatment competently, and others have a moral duty to respect their refusal. However, those with episodic mental disorders may wish to precommit themselves to treatment, using Ulysses contracts known as "mental health advance directives." How can health care providers justify enforcing such contracts over an agent's current, competent refusal? I argue that providers respect an agent's autonomy not retrospectively--by reference to his or her past wishes-and not merely synchronically--so that the agent gets what he or she wants right now-but diachronically and prospectively, acting so that the agent can shape his or her circumstances as the agent wishes over time, for the agent will experience the consequences of providers' actions over time. Mental health directives accomplish this, so they are a way of respecting the agent's autonomy even when providers override the agent's current competent refusal.     

The legal basis for the Danish committee on scientific dishonesty

The author, a High Court Judge, has chaired the Danish Committee on Scientific Dishonesty (DCSD) since its establishment in 1992. The Committee has worked in the health sector, but from 1999 the scope has been broadened to cover all fields of science. The article describes how the work is organised and the experiences gained. It is stressed, that the difficulty in connection with scientific dishonesty is, first and foremost, to organise a system suitable for investigating cases effectively, professionally, and with proper respect to the fundamental legal rights of the parties involved. The Committee has also spent much effort in determining what can be termed scientific dishonesty and what falls outside this category but which may, nevertheless, be characterised as breaching of good scientific practice. It is emphasised that these rules are not arbitrarily established by the Committee, but formulated in accordance with norms general accepted by opinion leaders in the scientific community. An carlier version of this paper was presented at a symposium, Scientific Misconduct. An International Perspective, organised by The Medical University of Warsaw, 16 November, 1998. The article is based on more comprehensive articles by the same author in DCSD’s Annual Reports for 1993 and 1995.     

Taking human life

Alan Donagan's position regarding the morality of taking innocent human life, that it is impermissible regardless of the wishes of the victim, is criticized by Brock who argues for a rights-based alternative. His argument appeals to the nature of persons' actual interest in life and gives them an additional element of control which they lack if a nonwaivable moral duty not to kill prevails. The author rejects Donagan's view that stopping a life-sustaining treatment, even when a competent patient has consented, is morally wrong and that there is no moral difference between killing and allowing to die. A rights-based position permits stopping treatment of incompetent patients based on what the patient would have wanted or what is in his or her best interest, and allows the withholding of treatment from a terminally ill person, with the patient's consent and for a benevolent motive, to be evaluated as morally different from killing that patient.     

Nameless Desire: Alexithymia and the Anorexic Patient

In this article, the author attempts to provide a psychoanalytic understanding of the anorexic patient who is disconnected from her affective experience and is considered to be alexithymic. Through her restrictive food ritual, this type of patient may organize her internal states by repeatedly creating an illusion of what it is that she needs and desires. The author asserts that the task of the therapist working with the anorexic patient with alexithymia is to be aware of his own sensation-based reverie as lived within the intersubjective arena. This will enable the therapist to assist the patient in building an affective vocabulary to accurately identify, differentiate, and label the internal signals of her body. It is suggested that the subjective emotional experience of the patient will continue to be reorganized, expanded, and enriched as the therapist and patient mutually influence one another in this unique relational matrix. A clinical vignette is provided to illustrate intersubjective treatment interventions with a difficult-to-reach anorexic patient.     

Firearms and the mentally ill: A legislative overview and jurisprudential analysis

This article examines federal and state laws that prohibit the mentally ill from possessing firearms and assesses the jurisprudence that has developed as courts have applied the federal law. It argues that although there is little or no empirical data linking the mentally ill with firearms violence, legislative activity and popular political debate invariably include such restrictions on the mentally ill. Notwithstanding the proliferation of firearms and antecedent violence, this article suggests that legislators and policy-makers must separate this issue from the broader and more emotional issue of “gun control” in order to effectuate better public policy and simultaneously protect the constitutional rights of the mentally ill.     

Between Hippocrates and God: Ugandan mental health professional's views on suicide

A negative attitude towards suicide is generally assumed to be predominant in low-income countries. In order to understand the negative attitude in general it is necessary to look at how religion and morality influence the attitudes. Our aim in this qualitative interview study was to investigate what attitudes professional mental health workers in Uganda bear towards suicide and suicidal persons. The professionals argue for their attitude by employing religious, communal and medical ethics arguments, which draw both in a negative and positive direction. The professionals are in general unambiguously negative towards suicide and positive towards suicidal people who are mentally ill. In cases other than mental illness non-accepting attitudes surface. This is discussed against previous research showing that effective treatment of suicidal people is to be based on a trusting and accepting relationship.     

Character and behavior in the mentally ill and well mother

The purpose of this study was to examine character and behavior in a group of mentally ill and well mothers. Mentally ill mothers differed from well mothers in mother-child interaction in their positive involvement in the feeding context and in overall optimal mothering during feeding. On measures of intrapsychic conflict and concern, mentally ill mothers demonstrated significantly more conflict in areas of trust, anger, self-esteem, mutuality and nurturance and more concern with issues of self-esteem, and giving and caring than well mothers. For the mentally ill mothers postpartum onset of illness and number of separations from her child were related to some aspects of character and behavior.     

Divine Hiddenness and Discrimination: A Philosophical Dilemma

Since its first delivery in 1993, J.L. Schellenberg’s atheistic argument from divine hiddenness keeps generating lively debate in various quarters in the philosophy of religion. Over time, the author has responded to many criticisms of his argument, both in its original evidentialist version and in its subsequent conceptualist version. One central problem that has gone undetected in these exchanges to date, we argue, is how Schellenberg’s explicit-recognition criterion for revelation contains discriminatory tendencies against mentally handicapped persons. Viewed from this angle, our present critique imparts Schellenberg’s position with a philosophical dilemma: (1) endorsing divine discrimination to the effect that God does not love ‘cognitive-affective outsiders’ or (2) giving up on explicit recognition. Either way, the hiddenness argument does not succeed.     

Selling the female image as mental patient

Tabulations of the sex and role (patient, helping professional, other) of all human images found in advertisements for psychoactive drugs in one half of the issues of The American Journal of Psychiatry from years 1963 to 1974 were made. Women were found to be portrayed as mentally ill significantly more often than men, while the images of men were used more frequently as doctors and others. These phenomena were discussed with references to attribution, suggestion, self-fulfilling prophecy, role playing, and the tendency to hospitalize, drug, and diagnose women as mentally ill.This article is based in part on a paper presented at the 83nd Annual Convention of the American Psychological Association, Chicago, September 1, 1975     

The Problem Of Retraction In Critical Discussion

In many contexts a retraction of commitment isfrowned upon. For instance, it is not appreciated,generally, if one withdraws a promise or denies anearlier statement. Critical discussion, too, caneasily be disrupted by retractions, if these occur toofrequently and at critical points. But on the otherhand, the very goal of critical discussion –resolution of a dispute – involves a retraction,either of doubt, or of some expressed point of view.A person who never retracts, not even under pressureof cogent arguments, would hardly qualify as areasonable discussant. Also, inconsistencies in one'sposition, once they have been pointed out, must bedealt with by some kind of retraction. The problem ofretraction is to find a suitable model of dialoguethat allows retractions where they seem reasonable, oreven required, and rules them out (or puts sanctionsupon them) whenever they would become disruptive of awell-organized process of dialogue.The present paper tries to point to a solution basedon the following principles: (1) Retraction rulesdetermine what retractions are permissible, and (2) ifpermissible what the consequences of retraction are.(3) Retraction rules vary according to the type ofdialogue and (4) according to the type of commitmentretracted. For instance, assertions and mereconcessions need to be distinguished, as well aslight-side and dark-side commitments. (5) To accountfor our contradictory intuitions on the issue ofretractions, one may best resort to a complex type ofdialogue in which different retraction rules hold fordifferent parts.The paper explains, summarizes, and expands upon thediscussion of retraction in Commitment inDialogue by Douglas Walton and the present author(cf. Walton and Krabbe 1995).     

Understanding public opinion relating to the establishment of community mental health facilities: implications of a discourse analytic approach

This paper demonstrates a novel approach to investigating the problem of public opposition to community mental health facilities. With the move towards community care, organizations setting up mental health facilities have encountered public opposition. It has been argued that this is due, in part, to the attitudes held by the public towards mentally ill people. A knowledge and understanding of attitudes towards this client group therefore has the potential to be of practical use to policy makers and practitioners who have a responsibility to consult on, and implement, community care for mentally ill people. The survey approaches and hypothetical situations used in previous British studies of community attitudes towards mentally ill people have, however, failed to take account of the rhetorical richness and complexity of the attitudes likely to be expressed in real‐life community care contexts. By contrast, the study reported in this paper used a discourse analytic approach to explore the views expressed about mentally ill people in a ‘hot situation’. Specifically, people's views were explored in the contexts of the arguments they used to challenge or advocate a supported accommodation project for mentally ill people in their community. This paper examines some of these arguments and discusses the theoretical implications for traditional approaches to attitude research. In conclusion, the potential practical utility of the findings is considered. Copyright © 1999 John Wiley & Sons, Ltd.     

病耻感对于精神病患者的影响以及文化对策

本文分析三种类型歧视所造成的患者及其家属的痛耻感,论述我们应当如何利用适当的文化应对策略来消除歧视、减少病耻感,从而有效地克服病耻感对于患者及其家属的负面影响。文化差异与病耻感的形成直接相关,文化作为一个重要变量,影响着精神卫生问题以及相应的服务政策,深入研究和认识儒家文化的核心价值有助于减少对于精神病患者的歧视,帮助他们克服病耻感。中国道家文化推崇道法自然,无为而治,可以发展出有效的心理疗法,对于精神疾病是一剂对症的良药。