Unfortunately, some clinicians mistakenly believe that a note from them virtually guarantees approval of a disability application--a belief that is often transmitted to patients. Similarly, Clark has seen her share of patients who show up armed with disability forms and the expectation that she will support their application. "I have lost patients because I've been unwilling to advocate for their desires regarding disability," Clark said.
Disability payments may be significantly delayed or even denied if a physician does not understand the idiosyncratic and often labyrinthine criteria of public and private disability plans. Problems also can arise if the physician, deliberately or inadvertently, does not provide enough relevant information to give a full understanding of the patient's clinical status. For example, a patient with bipolar disorder may be energetic and productive during a manic episode and clearly not meet disability criteria. Unless the treating psychiatrist also provides the patient's level of functioning during a depressive episode, reviewers will not gain a full understanding of the patient's average level of functioning, which may be quite poor. Clinical data about the side effects of a given medication are also important, particularly if the patient is employed in an occupation that puts them or others at risk of physical injury.Therapeutic Alliance
Doctors' attitudes toward disability payments can significantly affect the therapeutic alliance as well as the outcome of the disability process. For example, patients with schizophrenia may be seen as deserving of disability payments, while patients with Axis II difficulties may not be, particularly if they evoke strong countertransference in their clinicians.
A psychiatrist who has a long-term therapeutic relationship with a patient may feel pressure--either internal or from the patient--to advocate for disability, even if they do not believe the patient is disabled, for fear of harming the therapeutic alliance. Conversely, over-involvement in the role of patient advocate can muddy doctor-patient boundaries and encourage an inappropriate degree of dependency.
Treating clinicians may be legitimately concerned that receipt of disability benefits might encourage and/or reinforce dependency and interfere with a patient's incentive to make and retain therapeutic gains. Working with disability benefit recipients has "helped me to appreciate the adverse effect that idleness has on people," David Mischoulon, M.D., Ph.D., a psychiatrist at Massachusetts General Hospital in Boston, told PT. "It made me realize how bad it is when people get paid to be sick. It really becomes part of them, it consolidates the 'I am a mental patient and nothing else' identity."
The needs of employers also play a major role when it comes to determining if a patient is ready to go back to work. Employers "want to have their people return to work promptly, but they don't want people to come back who are unable to handle the work," Graff explained. He recalled the case of an employee on psychiatric disability for recurrent major depression with psychotic features. "The workplace didn't want him back until he was more or less perfect," he said. Ironically, the issue that most concerned the patient's employers was the fact that his medication was somewhat sedating. "They didn't get that he was psychotic."
Clark believes many problems in the therapeutic relationship can be avoided, or at least minimized, if doctor and patient openly discuss their views of the patient's perceived disability. "Discussion of disability allows you to really assess objectively, as well as to get the patients' sense of their strengths and weaknesses," said Clark, who always fills out disability forms with the patient during the regular office visit. "Often, people don't list their strengths particularly well." In addition, filling out the form together discourages patient passivity and removes the appearance of secrecy.
Graff thinks there is a dynamic tension between patients' expectations and the privileges doctors actually have. "If you're a doctor, you can do things that other people can't do," he said. "I can write a note that basically can cost someone thousands of dollars ... Doctors are given this power. In return, people come up to you and ask, or even demand, that you give them what they want." Graff said several patients each day ask him to fill out disability forms. There are so many that "What is that piece of paper in your hand?" has become a commonplace question during office visits.