The Trap of Stress Disability

stressThe other day I was asked to evaluate a fellow physician by his disability insurance company.  When I do disability assessments I take particular care, because what I say has big implications for the person I am evaluating, and I try very hard to do an extremely careful and thorough job of assessing the person’s situation.

Three quarters of the time what I end up concluding is that the person I am evaluating is indeed disabled and that the reason they’ve been disabled so long (I only usually do evaluations on people who have been on disability for six months to a year) is that they have not received adequate treatment. In these cases, my assessments are helpful in advocating for access to more intensive treatment for people with what has become a chronic depression.

However, that was not the situation last week.  I met with a cardiovascular surgeon who had immigrated to the United States from China 15 years ago and was working for a large medical group.  He had been doing excellent work, but the medical group hired a new chief of surgery, who apparently didn’t much like him and he started getting negative performance evaluations about a year ago.

Nine months ago, with his job on the line, he went out on disability for depression and stress.  I was asked to evaluate his progress in treatment and comment on his application to go out on permanent, long term, disability.

Long story short, my assessment was that his depression was not severe or chronic enough to explain his disability (there were a number of parts of his story that did not add up) and I thought that his decision to apply for permanent disability, soon after going out on short-term disability probably was a reflection, not so much of the severity of his depression, as of his wish to no longer work for his new Chief of Surgery.

This is a tricky situation and suspect that in this case, my assessment will not be helpful, which led to long periods of self-examination about what the right thing to do is in this situation.

In the process of thinking and rethinking about his situation, one thing that occurred to me was how much of a trap applying for disability had become for him.

As often seems to happen, whether consciously or unconsciously, he started retreating from his previously active life soon after he applied for disability, he stopped exercising, stopped going out with friends, began, in fact to act the role of someone with a severe disability.  So, here he was, free of the stress of working for a critical Chief of Surgery, free in fact to enjoy his life, but because he had applied for disability he became more and more disabled.

There’s a phenomenon that explains this called “cognitive dissonance.”  Cognitive dissonance refers to the fact that if you get someone to say something, even if they didn’t initially believe it, they will become more supportive of that position after they explain it to someone else. In other words, they will change their beliefs to match their behavior.

George Herbert Mead wrote a book called [amazon_link id=”0226516687″ target=”_blank” container=”” container_class=”” ]Mind, Self and Society[/amazon_link] in which he argues that we have a part of our mind that acts, makes decisions, does things (he called this part the “I”) and another part that observes and tries to understand (he called this the “me”). The “me” is the introjection of the attitudes of our parents and other important people in our lives (we learn to anticipate what our parents will think by taking in their thoughts and values, and this helps us to avoid being punished by them) . The “me” is the part of our self that allows us to be self-conscious. But the “me” has to form its conclusions about the “I” by observing what we do. In a way, we look at our behavior and we make conclusions about what we think and feel and believe based on what we say and do.

The doctor that I was evaluating, by deciding to apply for long-term disability had, I think, unconsciously concluded that he was disabled. And began to act as though he was disabled.

Of course, all of this could be because of depression, but the intriguing thing was that his disability was getting worse as his depression got better, and it seemed to get worse at roughly the time he applied for long-term disability.

This phenomenon has been also studied extensively in the case of people who make other kinds of stress claims or who file lawsuits based on stresses they are exposed to at work.  For many people, as long as they’re engaged in the lawsuit, they seem to become worse and worse and their lives become more miserable.

It is one of the reasons applying for disability is something to do very thoughtfully. It is not the wrong decision for everyone, depression can clearly make someone unable to function in a stressful work environment, but it has implications beyond the obvious ones.