Employment and Severe Mental Illness

To the Editor: I am prompted to write after reading the excellent article entitled "Policy Reform Dilemmas in Promoting Employment of Persons With Severe Mental Illnesses" by John H. Noble, Jr. (1), in the June 1998 issue. As a neurologist particularly interested in the neuropsychiatric field and closely involved with a local rescue mission that provides services for the homeless, I have been deeply impressed by Desjarlais' description (2) of the communication and cognitive functioning of persons with severe mental illness as presented in his monograph Shelter Blues.

His description is certainly concordant with my own clinical observations, which include the realization that clean-cut diagnostic criteria, as one sees in DSM-IV, simply do not work. Most of these individuals, who in fact are severely disabled, have injured their brains through drug use and have received brain injuries from head trauma. In addition, many of them started out with at least some cultural deprivation, if not birthright encephalopathies. Finally, they all have psychotic types of distortions in their internal cognitive perception, and also in their perceptions of the world. It is my firm conclusion that the concept of "employment" for this group of people is not only irrelevant but cruel.

Clearly, the basic services, such as nutrition, hygiene, essential medical care, and environmental safety, are where we should start. I do think that some of these individuals, perhaps not all, would be able to fashion daytime activities that would improve their quality of life. But they do not "get better" with habilitation or rehabilitation efforts. I have been impressed over the years that the concept of habilitation or rehabilitation of these severely impaired individuals creates an atmosphere of unrealistic expectations and, from some points of view, can be seen as a cruel hoax.

Dr. Noble's observation that "the big question is whether American society values these possible attainments enough to pay to make them more widely available" is to the point. Our culture seems not to be sufficiently empathetic to the problems and reality of disability.

Dr. Masland, who is in private practice, works with the Crossroads Mission in Yuma, Arizona.