Mar 21, 2013

Lessons from my Social Security caseload

Madness and I have been hanging out together a long time. Close to forty years now.

I met my first certifiably insane person in the late 1970s. After graduating from American University’s School of International Service, where I focused on political economics, cultural issues and bureaucratic process, I passed the Civil Service exam and found a job with the Social Security Administration. I worked on retirement, disability and SSI claims, and interviewed about a thousand people every year for eight years. One of my duties involved interviewing people being discharged from the former Longview State Hospital in Cincinnati.

Our staff paid an annual Christmas visit to the hospital. One year we hosted a small party on an inpatient ward for about twenty long-term residents, older adults with severe tardive dyskinesia (uncontrolled mouth and tongue movements). Four or five of the residents, seated in creaking old rocking chairs, advanced towards a young secretary as they rocked back and forth. When my co-worker started freaking out, the residents laughed like children caught by teacher in the middle of a grade school prank. We handed them glasses of punch.

One gentleman I interviewed in the office was being discharged after more than four decades in the hospital. He seemed kindly but a little disconnected, offering a small Southern town address when I searched for census records to establish his age. I later learned he was a forensic case, a child murderer sentenced to the institution decades earlier.

I also remember a young disabled Vietnam vet who wanted to re-establish contact with his estranged family. He returned to the office to thank me for forwarding a letter that helped them reunite. A few days later, his wife visited. I learned that my client was in the hospital, paralyzed after shooting himself, a botched suicide attempt. The reunion I thought was a success was merely a step along a self-destructive path. I had been taken in.

Social Security showed me how public policy decisions play out for people with mental illness. At one point the Reagan Administration changed evaluation procedures, stopping disability checks for thousands of people without any change occurring in the law itself. People with mental illness suffered greatly as their cases for reinstatement progressed through the court system. Many of these claimants failed to appeal their benefit terminations. Years later, the courts took note of their plight. Stacks of file folders were delivered to our office, each one representing a family who suffered with their benefit checks cut off unjustly.

My experience at Social Security helped me build my approach to recovery. I learned to focus on skills and capacities my clients retained, not on what they lost. I learned the value of supportive family members advocating for people they love. People who had allies were better able to cope with the demands of a complex bureaucratic system.

Social Security also taught me several key truths about systems: No matter how generous or effective they are meant to be, our systems are designed and operated by fallible people. Those of us who work in systems underestimate the people we serve, misjudge their capacities, make errors that lead to fatal or near-fatal consequences, act or fail to act with imperfect information. We can get stuck in formalistic thinking, hit limits with respect to our discretion, or improvise.

But even in the midst of systems burdened with errors, we can absolutely get things right. For every one of the trouble cases I remember, there were dozens of cases that we processed routinely and correctly. Good results pile up, but sometimes they accumulate in our blind spots.

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