Graff does not think patients seeking disability benefits are more entitled than other patients, but believes patients in general feel increasingly entitled and have greater expectations of treaters. In the case of those seeking disability, an attitude of entitlement can strain the therapeutic relationship, particularly if the clinician does not believe the patient is disabled but is "playing the system" for the sake of financial gain.
It has been theorized that disability-seeking behavior "may also represent a characterological trait, particularly in those who are less disabled å Further research may help clarify whether disability is an independent entity, or a form of a mixed personality disorder" (Mischoulon, 1999).Talking to Patients
The task of talking to patients applying for disability can be a delicate one. Unwanted changes in job responsibilities or conflicts with supervisors or co-workers frequently are cited by these patients, who often are surprised to learn the actual degree of disability required to meet the eligibility criteria of federal agencies and/or private employers. For example, patients may mistakenly believe they are entitled to disability benefits if they are unable to perform job responsibilities in their given field. In fact, SSA regulations (2002) define disability as "the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." Clark said, "There are patients who feel they should be [judged] disabled if they can't do the job of their choice."
Consequently, familiarity with disability guidelines can serve to give these patients a realistic sense of the chances that their application will be approved and can create an opportunity to generate alternative, empowering solutions. Similarly, questions about specific job responsibilities can pinpoint areas of strength, as well as difficulty.
Mischoulon suggests that clinicians adopt a stance of cautious pessimism when talking with patients about the probability of receiving benefits (Mischoulon, 2002). If a psychiatrist does not believe their patient is disabled, Mischoulon suggests that the clinician share this impression with the patient. Specifically, Mishoulon recommends that the psychiatrist tell the patient that they believe the petition for disability to be an indirect way of getting personal needs met. Remaining empathic with the patient's wish to be taken care of while inviting them to actively participate in generating alternative ways to get needs met can go a long way toward preserving the therapeutic alliance while maintaining focus on negotiated treatment goals. If a patient is deemed eligible for benefits, work should continue to maintain clinical momentum, which, for seriously and chronically ill patients, may mean working toward a return to baseline functioning.
Clark does not discuss disability as a permanent situation with patients, even if their prognosis is poor. "My goal is to get them to the highest level of functioning," she explained.