Andrew O. Brown, MD

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Problems with any one of these domains can disrupt an individual’s capacity to sustain work capacity.

5 Domains of Functional Assessment for Disability Evaluation

FROM THE GROUP FOR THE ADVANCEMENT OF PSYCHIATRY

This article discusses the return to work plan as a solution to the clinical and systemic problems arising from psychiatric disability. The systems that govern administration of “disability” benefits should be guided by:

 The treating psychiatrist is relieved of the fear that if he or she acknowledges the truth, ie, the presence of (or potential for) preserved work capacity, his or her patient will suffer.

 The patient is supported for engaging in behaviors that are reasonably expected to culminate in restoration of the work-reward relationship and a healthy patient-psychiatrist-workplace system.

Among many problems inherent in the American disability system is the medicalization of work stress and its inappropriate conversion into psychiatric diagnoses, which implies impaired or loss of ability to function. This “medicalization” decouples the normal work-reward dynamic in a way that reinforces disability-seeking behaviors. Potential solutions to problems of disability require a multisystemic approach. In the psychiatrist’s office, solutions include the paradigm of “truth and resolution”; in practice, the re-coupling of work and reward as a goal, and support for disability reform (eg, the use of standardized functional assessments) but with careful consideration of its possible consequences.

Psychiatrists’ challenges to disability claims

There are challenges to the psychiatrist’s support of a patient’s claim for disability. While it seems obvious that a psychiatrist simply wants to diagnose accurately and make appropriate recommendations, the situation around disability is wrought with pitfalls and is quite complicated. The addition of an economic, potentially income-providing relationship forever changes the treatment dynamic. Supporting a disability claim could mean both administrative (in the form of documents initially justifying, then recertifying the claim) and legal (requiring other documentation or testimony related to the assessment) liabilities. Withholding support for disability benefits could lead to anger, violence, medical board complaints, negative online reviews, or litigation on the part of the patient. The psychiatrist might also feel burdened with significant counter-transference guilt.

A solution to this is “truth and resolution.” These best practices allow psychiatrists to conduct patient care in such a way that they can acknowledge the objective reality of return to work. It includes recognizing the pitfalls of misdiagnosis as well as potential excessive physical, emotional, and financial expense to the patient, the employer, family members, and medical specialists and administrators. These expenses can include unnecessary workups, treatment referrals, and cost to systems as benefits are paid and work production is lost, and the beginning of a process that can result in lifetime disability for a patient.

“Truth and resolution” as a treatment approach ensures that providers “first do no harm.” Importantly, it requires training in occupational assessment, which has been a noted weakness among psychiatrists. This training would include review of the difference between impairment and disability, discerning patient job requirements in interviews, consideration of somatic symptom disorders, and curricula that addresses the implications of a patient’s engagement with a disability system and prognostic factors affecting a return-to-work.

The idea of promoting patient behaviors oriented toward restoring the work-reward relationship is an intuitive one which has been investigated in studies of disability and return-to-work across several medical specialties. Some approaches have focused on workplace accommodations. A 1998 review found that patients offered modified work after a workplace injury were about two times more likely to return-to-work than those who were not.

 A 2005 systematic review found that the duration of disability for patients with musculoskeletal and other pain conditions was reduced by offers of work accommodations and communications between medical providers and employers.

Other approaches to the return-to-work have considered stress and perception of support at work. A 2002 literature review found that a “non-supportive work environment” was associated with disability or retirement for cancer survivors.

 A later study found that “perceived employer discrimination” led to lower return-to-work rates for breast cancer survivors.

 Conversely, a 1998 prospective cohort study found that strong social support was a feature of patients who returned to work after lower extremity fractures.

 This suggests that interventions aiming to encourage actual or perceived support in the workplace could improve chances of a patient’s return.

Investigators have researched therapy when high work stress is identified. In a small Dutch study, patients with adjustment disorders were more likely to return to work and return to work earlier if they were treated with an activating, stress awareness training much like stress-inoculation training.

 Physician interventions in return-to-work and disability scenarios have also have some limits. Dasinger and colleagues

 found that a physician’s proactive communication consisting of understanding, questions, and recommendations about the patient’s work and workplace was associated with patients’ return to work within the first 30 days of disability for low back pain. Moreover, a physician’s explicit recommendation for returning to work was associated with a nearly 60% increase in return-to-work rates in patients with more than 30 days of disability. Unfortunately, these effects disappear in the first case and nearly lose statistical significance in the latter case when workers reported “high job strain” in the workplace.

In addition to changes in clinical approaches between doctor, patient, and employer, government systems have attempted systemic changes in assessments in attempts to reform disability systems. In this process, however, significant consideration must be paid to repercussions of changes made to vital disability benefit systems. In recent years, the United Kingdom has adopted a new functional assessment tool, the Work Capability Assessment (WCA). This tool has been used not only to assess new disability claimants, but also to reassess more objectively over 1 million claimants who had already been granted disability benefits.

Recently published research reveals that the WCA reassessment process was associated with increases in behavioral health symptoms, antidepressant prescribing, and completed suicides.

 To date, other nations conducting similar disability system reform (eg, the Netherlands, Australia) have not reported such trends. Still, the far-reaching social impact of such programs must be considered before the implementation of systemic disability reform.

Dr Long is Committee Chair, Work and Disability Consultant Private Industry, the Courts, and the Legal Profession; Dr Flinton is a Child and Adolescent Fellow in the National Capital Consortium, Walter Reed National Military Medical Center, Bethesda, MD; Dr Brown is Department Psychiatrist, Boston Police Department, Consulting Psychiatrist, Boston Fire Department, Work and Disability Consultant, Private Industry and Government; Dr Sassano-Higgins is Adjunct Professor, Department of Psychiatry, University of Southern California; Dr Morrison is Clinical Assistant Professor of Psychiatry and Behavioral Sciences, Chicago Medical School.

The views expressed in this article are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government.

1. Krause N, Dasinger LK, Neuhauser F. Modified work and returns to work: a review of the literature. 

2. Franche RL, Cullen K, Clarke J, et al. Workplace-based return-to-work interventions: A systematic review of the quantitative literature. 

3. Spelten ER, Sprangers MAG, Verbeek JHAM. Factors reported to influence the return to work of cancer survivors: a literature review. 

4. Bouknight RR, Bradley CJ, Luo ZH. Correlates of return to work for breast cancer survivors. 

5. MacKenzie EJ, Morris JA, Jurkovich GJ, et al. Return to work following injury: the role of economic, social, and job-related factors. 

6. Van der Klink JJL, Blonk RWB, Schene AH, et al. Reducing long term sickness absence by an activating intervention in adjustment disorders: a cluster randomized controlled design. 

7. Dasinger LK, Krause N, Thompson PJ, et al. Doctor proactive communication, return-to-work recommendation, and duration of disability after a workers’ compensation low back injury. 

8. Barr B, Taylor-Robinson D, Stuckler D, et al. “First, do no harm”: are disability assessments associated with adverse trends in mental health? A longitudinal ecological study. 

Articles

This article discusses the return to work plan as a solution to the clinical and systemic problems arising from psychiatric disability.

Disability and the Concept of Return to Work

For the Committee on Work and Organizations, From the Group for the Advancement of Psychiatry

Imagine: Your patient has complained about a disagreement with his boss, who he thinks is criticizing him unfairly. You have prescribed an antidepressant and have been helping the patient communicate better with the boss, but the hostility between the two has escalated, and the boss terminated him. At his request, you supported his application for Social Security Disability Insurance (SSDI).

His application was denied, and he is suing SSDI for the denial and his former employer for discrimination based on the Americans With Disabilities Act (ADA). He wants you to provide a forensic expert psychiatric opinion that he is disabled, and that the denial of benefits has psychologically damaged him permanently. You feel caught in a bind, and you are. By stepping out of the treater role, either into the role of disability evaluator or forensic expert, you assume risks inherent in this role combination.

This article highlights some of these major risks. The take-home point is that treaters should avoid role duality if at all possible, preserving the role as treater and referring disability and forensic evaluations to a colleague trained in this area. The following principles apply to psychiatrists who are asked either to support a patient’s disability application or offer forensic expert opinions if litigation ultimately ensues because disability is denied.

The treater is an advocate for the patient’s mental health. The treater absorbs what the patient says without question and makes treatment decisions accordingly, viewing suspected distortions or exaggerations only as part of a complicated clinical picture. If the treater suspects malingering, treatment is terminated.

In the role of disability assessor or forensic consultant/expert, the psychiatrist is not an advocate for the litigant, instead he or she strives for honesty and impartiality in the assessment. Especially as expert, any signs of advocacy for the litigant leaves the expert open to a challenge of bias from the opposing side and may result in the expert’s being discredited by the fact-finder.

A possible exception exists in the case of a patient with acute and unambiguous impairment and debilitation (eg, florid psychosis, delirium, mania, profound neuro-vegetative depression) in which an appropriately qualified forensic expert cannot be obtained, the treater has not conducted the disability functional assessment, and the patient has been denied disability benefits. Since the psychiatric conditions listed create functional impairment and therefore are generally considered to be disabling, at least temporarily, the treater may be obliged to render an expert opinion in court.

Ethics require that information divulged in treatment sessions remains confidential. If the treater has also agreed to be the patient’s disability assessor or forensic expert, an ethical bind results, particularly in the latter role. In practicing within ethical guidelines the disability examiner or expert advises the litigant that there is no treatment relationship and no confidentiality exists in the interview. Anything discussed in the interview might appear in the report, which will be shared with either the disability insurance company and employer (if a disability exam) or the attorneys involved in the litigation process. In embracing dual roles, the treater who has breached patient confidentiality in order to provide a complete and honest opinion risks not only the patient’s angry termination of treatment but also an ethics complaint or even a retaliatory malpractice lawsuit.

If the treater should become incapacitated, die, retire, or take an extended leave of absence, the replacement treater should be able to garner the important treatment issues from the record. If the treater is also the disability assessor or forensic expert and the patient shares crucial information that could harm the disability claim or legal case, the treater faces another bind. Documenting this may be the ethical choice but risks termination and/or retaliation by an angry patient if the disability or legal case suffers accordingly, not to mention worsening of the patient’s mental health. This bind can lead the treater to sanitize the record, thereby including only medications and benign information and omitting any potentially damaging therapeutic revelations. An independent disability assessor or forensic expert does not have this bind since no treatment relationship exists.

The treater focuses on helping the patient rather than formulating opinions on diagnosis and causality of symptoms. Many treaters conduct a limited mental status examination, if any, and instead focus on current symptoms.

The disability examiner needs to conduct a comprehensive evaluation and functional assessment so that an independent opinion on disability can be rendered. The forensic examiner must defend opinions on both diagnosis and causality of the diagnosis in deposition or at trial, since valid legal claims of emotional injury are translated into psychiatric diagnoses caused by the disputed circumstances.

The disability examiner should review collateral information, especially work records, but additionally must understand the mental functions required by the job and explain how any psychiatric diagnoses impair the person’s ability to carry out the job tasks. Psychological testing may be useful.

The expert must also defend the diagnostic opinions by reviewing multiple cross-sectional sources of information including mental health, medical, employment, legal, and other pertinent records. Objective psychological testing is important in order to check for consistency with the diagnostic hypotheses. In either role, a complete mental status examination is essential.

In addition to the psychiatric diagnoses, the disability examiner must discuss any collateral factors that may underlie the request for disability, such as family problems and severe financial problems, as with the IRS and creditors. Some diagnoses, such as PTSD, are easily malingered by review of symptoms posted online. Treaters involved with the Veteran’s Administration clinics and hospitals in which PTSD checklists are administered routinely face a unique responsibility to minimize inappropriate use of the system by these patients.

Although treaters may initially obtain information about the patient’s medical, mental health, developmental, and family histories, rarely does inquiry go beyond these areas-often because of time limitations. Follow-up sessions are usually brief checks that inquire about response to medications and adverse effects without discussion of other issues such as current life circumstances and collateral stresses.

By contrast, the disability or forensic examiner usually has a single interview in which to gather sufficient information to formulate opinions regarding diagnosis and causality. This usually results in a lengthy inquiry into historical and present circumstances without any follow up. The disability exam involves a functional assessment, which may not be required in a forensic evaluation.

The treater makes arrangements with the patient for the payment of services. Disability examiners contract with insurance companies or independent third parties to conduct the exam; the particulars and payment are decided at that time, and the fee may be different than that charged for treatment.

Forensic examiners usually contract with the retaining attorney regarding payment for time and expenses to conduct the examination. Usually forensic consultation is more costly than treatment. If treaters also assume the forensic role and charge more accordingly, questions arise such as who is responsible for payment of services. Usually it is the litigant’s attorney, but if the psychiatrist is also providing treatment, attorneys may ask that the evaluation be charged to the patient’s medical insurance provider. This creates another ethical problem: what portion of services should be described as treatment and what is the risk to the treater for an ethical complaint because of disparate charges for treatment versus expert work?

The treater who also assumes the dual role as either a disability examiner or forensic consulting expert faces ethical risks because of the inherent binds in the dual role, including advocacy, confidentiality, integrity of the medical record, diagnosis, causality, limited inquiry, and financial reimbursement. Dual roles leave the treater opining on the patient’s disability claim open to question by the disability insurer, who may then request an independent assessment.

If the treater is also the forensic expert, he or she will be open to attack by opposing attorney at deposition and trial, and the treater/examiner’s credibility, impartiality, and motives for functioning in this dual role may be questioned and memorialized in the public legal record. Worse, if the treater/forensic expert testifies at trial while the patient watches a withering cross-examination by opposing counsel, the patient’s legal case may be compromised and lost. How will the patient/litigant respond to the treater’s loss of credibility? Will the patient terminate treatment and retaliate legally against the treater?

These are some of the important reasons why, barring certain exceptions, treaters who are asked by their patients to function as a disability assessor or forensic expert should strongly consider declining and remaining in the treatment role alone, referring the patient to an appropriately trained colleague. If asked to testify for the patient, the treater may testify as a fact, but not an expert witness. A possible exception exists when a patient who exhibits signs of acute and unambiguous impairment and debilitation has been denied disability benefits, and a qualified disability examiner or forensic expert cannot be obtained. Such conditions may temporarily require the treater’s assuming a dual role, but the treater should document the reasons for role duality and the limitations this imposes on the treatment process of treatment and disability or forensic assessment, clearly explaining these limitations to the patient, insurer, and the courts.

Dr Long is Committee Chair, Work and Disability Consultant Private Industry, the Courts, and the Legal Profession; Dr Brown is Department Psychiatrist, Boston Police Department, Consulting Psychiatrist, Boston Fire Department, Work and Disability Consultant, Private Industry and Government; Dr Sassano-Higgins is Adjunct Professor, Department of Psychiatry, University of Southern California; Dr Morrison is Clinical Assistant Professor of Psychiatry and Behavioral Sciences, Chicago Medical School.

The treater who assumes a dual role as either disability examiner or forensic expert faces ethical risks because of the inherent binds in the roles.

Treater, Disability Assessor, or Forensic Expert: A Trap in Disability Claims

From the Committee on Work and Organizations, Group for the Advancement of Psychiatry

One of the most perplexing challenges for psychiatrists who interact with the workplace is the competing forces for and against mental health. As previously argued, work is of paramount importance for the mental health of any person, especially an adult.

 Building off of what we have argued to this point, the intersection of work, health, the patient, and the doctor becomes decoupled as disability is considered. If returning to work is not thoughtfully planned for, the whole delicate web can fall apart.

We are a group of psychiatric professionals whose work varies. At times we are focused 100% on clinical, other times we are 100% focused on the work environment, and much of the time we are focused on the intersection. This 

 exploration of work and disability focuses on the challenges of the workplace manager, the employee with whom there is a conflict related to performance, and the psychiatrist who is tasked with the challenge to determine disability.

For many of the cases we see there is a great deal of ambiguity or gray space. There are some cases where there is clear evidence of the onset of a mental illness independent of workplace dynamics, yet in many others there is not. As in all systems, there is a critical balance to find between what is pathological and what is supporting mental health.

How might the psychiatrist support mental health at work?

To the workplace organization, the mental health system seems fraught with traps to undermine productivity: decreased production, lost hours, and distracted and “on edge” supervisors all tracking back to performance issues of employees. For managers, the role becomes confusing and even frustrating. They most likely do not know what “toxic” means, much less how to handle “periods of irritability, down moods,” or how to grant “occasional time to be away from work.”

Many managers are not trained in the various regulations such as the Family and Medical Leave Act (FMLA), and they can be particularly perplexed by options for dealing with employees who are distressed to the point of distraction and deteriorating performance. In fact, although not always written explicitly, the manager feels incompetent because the psychiatrist or the plan generated by the Employee Assistance Program (EAP) carries with it many implicit requests “to be a therapist.”

On the psychiatrist’s side of things, the doctor is at risk of unspoken feelings of incompetence as well. Physicians are trained to be knowledgeable and confident in their point of view, and a treatment plan is the foundation of this training. Yet, most psychiatrists are quickly out of synch with the workplace as it relates to disability.

Here is an abbreviated list of why psychiatrists can also feel incompetent:

 They have not been trained to see the workplace from the managers’ point of view.

 They do not know how to analyze a system like a workplace or a work environment that can include interacting internationally or virtually, and to decide who is responsible for what aspect of the work flow.

 The terms toxic, stress, and even PTSD are often used imprecisely in the workplace without the discipline or clarity typically used in medical assessments and treatment plans.

 Their allotted time with patients is shrinking.

 The expertise on the Internet to pursue disability is large and growing every day creating an asymmetric knowledge for the doctor compared with the employee.

 Most psychiatrists do not understand effective and ineffective performance management systems or competent leaders of healthy workplace cultures.

In our preliminary survey-based research, “Psychiatry of Workplace Dysfunction-Tools for Mental Health Professionals, Managers, and Employees,” the findings indicate that psychiatrists generally feel incompetent addressing common psychiatric challenges to the workplace, such as how to compose a thoughtful return to work plan.

 Moreover, the survey findings suggest that residency training directors feel unprepared to design curricula that cover these shortfalls.

In the end, the patient’s anxiety about returning to work combined with direction from family, friends, or the Internet has the potential to cause the patient to single-mindedly pursue disability. The powerful emotional affects generated in the sessions about returning to work overwhelm the treating doctor and the worker patient. The compounding forces to pursue disability create demands on the patient and on the psychiatrist. This combined with the distress of an overwhelmed manager leads to an adversarial and misaligned system that rapidly escalates. Thus, ironically the employee, psychiatrist, and manager all play a role in the decline of the overall mental health of patients. Specifically, it harms the ability of the patient and the manager to learn how to resolve conflict.

This is not new. Our committee has explored this dynamic for over 40 years with the original position paper, “What Price Compensation.”

Long absences from work make it difficult to return to work, for a number of reasons:

• The anxiety associated with being accepted back into the group

• The unconscious tendency of the group to exclude fellow members during their absence

• The concern about being able to perform one’s duties at excellent levels

• The effect of injury on one’s self-esteem during the period of “doing nothing and not contributing”

There is a missing piece that can help the manager, the psychiatrist, and the employee find common ground: a pathway to returning to work while managing mental illness and its sequelae. Our larger mission is to support both the managers at work as well as psychiatrists with their patients to understand the forces leading to mental health.

In the previous article in our series on disability we highlighted the need to address the concept of functional assessment.

 It is important to note, however, that because symptoms are subjective, functional assessments don’t always provide a true picture of the patient’s disability. If the patient is being coached on how to respond to assessments, the problems affecting the doctor-patient and/or the employee-manager relationships are worsened. Psychiatrists must work with the patient to improve functioning gradually, paralleling the return to work plans that are regularly used by other medical practitioners (eg, orthopedists). The goal is to avoid permanently eliminating work from patients’ lives.

 Long B, Brown AO, Sassano-Higgins S, et al. A complicated case of psychiatric disability. 

 Long B, Brown AO, Sassano-Higgins S, et al. Disability: overview of concepts psychiatrists need to know. 

 Long B, Brown AO, Sassano-Higgins S, et al. Functional assessment for disability applications: tools for the psychiatrist. 

 Long B, Brown AO, Sassano-Higgins S, et al. The psychiatry of work: is residency training adequate? 

 Group for the Advancement of Psychiatry. What Price Compensation? Committee on Psychiatry in Industry, Vol IX, Publication No. 99; June 1977.

 Committee on Work and Organizations, Group for the Advancement of Psychiatry. 

Psychiatry of Workplace Dysfunction: Tools for Mental Health Professionals, Managers, and Employees

. New York: Oxford University Press; 2018.

One of the most perplexing challenges for psychiatrists who interact with the workplace is the competing forces for and against mental health.

The Disabled Employee’s Manager: A Common Complicating Factor of Workplace Disability

Committee on Work and Organizations, Group for the Advancement of Psychiatry

A 47-year-old project manager presents with a 5-week history of sleep disturbance and other symptoms of generalized anxiety. Three months earlier her manager had retired and a new supervisor was introduced. Whereas her former manager had consistently praised the patient’s job performance and valued her contribution to the firm, her new manager seems to do nothing but find fault with her work.xx

Two weeks before presenting to your office, the patient was placed on a Performance Plan by the new manager. She reports that since then her fears about the prospect of job termination have intensified to the point that she cannot concentrate and is making mistakes at work. One week before this visit she reports having a “panic attack” as she was preparing to go to work and did not go. She has not been to work for one week and is scared to return for fear that she will continue to make mistakes, which will culminate in-and be used by the new manager to justify-her termination. As your office visit with her draws to a close, she asks you to complete documentation that she will use to claim disability.

This case illustrates a problem commonly faced by psychiatrists-assessing a patient’s claim of disability. As this series discusses, there are two major issues to keep in mind: avoiding role duality, which will be discussed in a subsequent article in this series; and using an objective tool to evaluate a claim of disability and determine whether functional impairment, if present, can be reversed, and the patient can return to work.

In this article we discuss such a tool-the Functional Assessment. A Functional Assessment seeks to determine whether an individual’s capacity to execute occupationally relevant mental functions is compromised. This is accomplished by identifying the specific work-relevant mental function that is compromised, describing how the work-relevant mental function is compromised, and assessing the extent to which the work-relevant mental function is compromised.

In addressing functional capacity to work, DSM, in its categorization of mental disorders, is of limited use. A DSM diagnosis may be relevant to understanding why a work-relevant mental function has been compromised, but the diagnosis does not identify the specific mental function that has been compromised or explain why or how the mental function precludes the individual’s capacity to work. One individual with a specific psychiatric diagnosis may perform well at work while another with the same level of symptomatology and diagnosis, working at the same occupation, may claim work incapacity attributable to the diagnosis.

The specific mental functions that most commonly disrupt an individual’s capacity to sustain work capacity include:

 This functional domain refers to the individual’s capacity to communicate, cooperate, and collaborate with peers, subordinates, or authority figures at the workplace.

 The mental functions that subserve adaptability and flexibility relate to an individual’s capacity to change perspective in response to changing demands in the external world.

 These relate to an individual’s capacity to be consistently relied upon to perform the duties that he or she is charged to perform.

 Usually the impulses that are most likely to impair an individual’s capacity to work relate to anger and aggression, but any impaired capacity to control behavior can preclude work capacity.

Integrity relates to, but encompasses more than, truthfulness and involves the consistency between an individual’s words and his or her actions, ie, whether he or she “walks the walk” in addition to “talking the talk.” This functional domain is generally more relevant to assessing an individual’s suitability to perform a specific occupation rather than his or her general capacity to work.

Emotional regulation refers to an individual’s capacity to contain emotional responses adequately so that such responses do not interfere with job-relevant mental functions.

 The level of judgment required of work is to a large extent contingent upon the individual’s occupation. As when evaluating a patient’s competency to consent to treatment, the psychiatrist must determine: does the individual have the relevant knowledge to perform this job? Does the individual understand how the knowledge base relates to his or her specific duties? Does the individual have the sound judgment to examine the relevant facts in a specific situation to be able to make a good decision?

This domain involves making DSM diagnoses and is an important component of a functional assessment, because individuals with active substance use disorders are automatically precluded from performing many types of work, ie, safety sensitive jobs, and because global impairment of work-relevant mental functions is typically seen in intoxication.

 This domain, which relates to impulsivity, decision-making, and judgment, is important to assess in general. However, it is particularly important in safety sensitive jobs such as law enforcement, firefighting, medicine, and other jobs where poor judgment can lead to catastrophic consequences.

 If cognitive impairment is present, the specific job-relevant cognitive function that is disrupted should be identified.

Functional Assessment should address treatment, ie, whether and how a functional impairment can be reversed. The most effective functional evaluations do not refer to generic treatment modalities such as “psychopharmacology” or “cognitive-behavioral therapy.” Instead, they focus on identifying the precise work-relevant functional impairment; explaining how and why the recommended treatment can be reasonably expected to reverse the specific functional impairment, and, in so doing, return the afflicted individual to work; and establishing a reasonable time frame during which the work-relevant functional impairment can be expected to be reversed given the patient’s full compliance with the recommended treatment.

By employing the tools of a Functional Assessment, psychiatrists can introduce a more objective standard that is needed in disability evaluations and prognosis for a return to work.

Dr Long and her co-authors make a compelling case for the value of a Functional Assessment in facilitating decision-making regarding a patient’s capacity to work and, when appropriate, utilizing this approach to support a claim for disability.

This article carefully reviews a number of key domains of mental functioning which, when compromised, can significantly disrupt a patient’s ability to adequately cope with the demands of his/her job. There are other domains that warrant mention: Planning, prioritization and organizational capacities/skills, task initiation/monitoring and time management. 

Self–monitoring is another important domain germane to work capacity. It refers to a patient’s awareness/insight regarding the degree to which his/her attitudes/feelings may be negatively affecting the attitudes/feelings of others in the workplace. This domain also encompasses the capacity for a realistic appraisal of personal assets and debits as they pertain to a patient’s “match” with the challenges of his/her job.

Left unaddressed in this article is the judicious use of standardized self-report and informant report rating scales as well as psychological/neuropsychological tests to generate a clinical profile of intact and disrupted mental functions together with remedial interventions which may help the patient compensate for weaker areas of functioning at work. This includes measures of executive functioning like the Behavior Rating Inventory of Executive Function/BRIEF and the Comprehensive Executive Function Inventory/CFI as well as tests of adaptive functioning, notably the Adaptive Behavior Assessment System-3/ABAS-3. Other helpful tools include the Global Functioning Social and Role Scales.

Jerrold Pollak, PhD
	Clinical and Neuropsychologist
	Portsmouth, NH

Dr Long is Committee Chair, Work and Disability Consultant Private Industry, the Courts, and the Legal Profession; Dr Brown is Department Psychiatrist, Boston Police Department, Consulting Psychiatrist, Boston Fire Department, Work and Disability Consultant, Private Industry and Government; Dr Sassano-Higgins is Adjunct Professor, Department of Psychiatry, University of Southern California; Dr Morrison is Clinical Assistant Professor of Psychiatry and Behavioral Sciences, Chicago Medical School. 

These 10 domains will help you determine if functional impairment exists, if it can be reversed, and if the patient can return to work.

Functional Assessment  for Disability Applications: Tools for the Psychiatrist

As in the case of “Bob,” whom you met in our 

, patients frequently ask psychiatrists to be “put on disability.”

 Such requests typically require that the psychiatrist complete documents confirming the patient’s inability to work. While patients claim work incapacity for a variety of reasons, in claiming disability patients are separating themselves from a situation, event, or demand at the workplace. The patient may have difficulty completing work-related tasks or may feel the need to avoid the workplace for some other reason.

Although patients are typically self-directed in their decision to seek disability, it is not uncommon for patients to lack an understanding of the intent and purpose of “disability” programs. It is also common for human resources personnel to advise employees to claim disability when a workplace problem is brought to their attention. This article discusses the risks of supporting versus withholding support for a patient’s disability claim and six key definitions psychiatrists need to understand when they are asked by patients to support such a claim.

Disability. Disability is a legal and administrative construct that refers to an individual’s eligibility to receive benefits from an institution, government, or society at large. Because one’s eligibility to receive benefits is contingent upon the terms of specific contracts, laws, and policies, disability is not a medical or clinical concept. Government agencies (such as the Social Security Administration), insurance companies, or the courts-rather than physicians-determine whether an individual is disabled.

Functional impairment. Functional impairment is present when a pathological condition has weakened or damaged an individual’s capacity to execute a mental function. A delusion, for example, can impair an individual’s judgment and ability to make sensible decisions, while mania can impair behavior and impulse control.

Although functional impairment can be attributed to a psychiatric diagnosis, functional impairment does not in itself constitute a diagnosis. Moreover, a psychiatric diagnosis does not necessarily result in a functional impairment that precludes employment. For example, the vast majority of patients seen in a typical outpatient psychiatric practice have a diagnosis of a psychiatric disorder, but only a very small percentage have symptoms that would preclude the ability to engage in gainful employment.

Restriction. Restriction is a type of activity that an individual should not perform because performance of such activity can be reasonably expected to worsen an illness or disease. It may be reasonable to restrict an individual with bipolar I disorder from performing irregular work shifts, for example, because disruption of the patient’s sleep-wake cycle can be reasonably expected to exacerbate the disorder.

Limitation. A person with a limitation has a compromised capacity to perform an activity due to the presence of a specific functional impairment. For example, an individual who manifests profound levels of psychomotor retardation attributable to severe Major Depressive Disorder may be limited in his or her capacity to arrive on time for their scheduled work hours.

Impairment versus disability. An individual may manifest impairment, restrictions, and limitations and yet not be prevented from performing the duties of his occupation. For an individual to manifest disability as a result of impairment, the identified impairment would need to be considered occupationally relevant. For example, individuals with functionally impairing levels of social anxiety disorder may be limited in their capacity to give presentations, but if their occupation does not require that they give presentations, such impairment and limitations would not preclude them from performing the duties of the job. The institution adjudicating such claims would probably acknowledge that these individuals are “impaired” but would not consider them “disabled.”

Short-term versus long-term disability. Patients may have a condition that prevents them from working at a current job but that does not prevent them from working in a different position (such as for a different manager, boss, or employer). Short-term disability is often used when individuals experience a problem that prevents them from performing their job duties under their current employer but not necessarily under a different one.

Two problems typically ensue when an individual transitions from “short-term” to “long-term” disability status. First, the likelihood that the patient will ever return to work in his or her occupation (or gainful employment in general) is sharply reduced. Second, the terms governing the patient’s disability status change. For example, the patient’s claims may be adjudicated based on whether the patient can perform the duties of an occupation anywhere or whether he or she can complete the duties of the occupation and/or the specific job under a specific employer.

Responding to the patient who claims disability

Requests for disability may induce a range of reactions in psychiatrists. Positive feelings arise when the request impresses the psychiatrist as reasonable or indicated, or when such requests gratify the psychiatrist’s inclination to advocate for a patient in need. Negative feelings can also occur if treaters feel that their services are being used inappropriately, or if they feel the request is opportunistic, counterproductive, or counter-therapeutic. Because countertransference reactions can be intense, best practices involve psychiatrists’ being aware of the emotions that arise when a patient asserts disability.

Disability requests almost always create a quandary for psychiatrists, who face risks regardless of whether they support or disengage from such claims.

The physician’s quandary: risks of supporting and withholding support

Because psychiatric treatment strives to improve the patient’s mental health and functioning, the effectiveness of treatment may be compromised if the true purpose of treatment is transformed into a means by which the patient can receive economic support by demonstrating illness and incapacity.

An administrative burden may be created because the physician is required to recertify disability on an ongoing basis.

Role confusion is possible if the psychiatrist serves dual roles as disability evaluator and treater for the same patient. The risks are amplified if disability is denied, litigation ensues, and the patient or attorney asks the treater to provide forensic expert opinions on diagnosis, causality, and “permanence of disability.”

Legal and licensure entanglements may ensue, eg, the psychiatrist may be asked on a disability application to swear findings are accurate under penalty of perjury.

The patient may decide to complain to the state medical board

The patient may write negative online reviews.

Your decision may result in anger and possible violence on the patient’s part.

You may become a victim of countertransference with feeling of guilt: “I am a bad doctor for not supporting my patient;” “My patient won’t like me, he may decide to stop treatment.”

Psychiatrists must utilize specific concepts when they assess patients who claim work incapacity. Adequate understanding of the six key definitions on the previous page is critically important as such concepts guide assessment and treatment of the patient and will ultimately inform adjudication of the patient’s disability claim.

Approach to a functional assessment of claimed disability

The determination of disability requires an understanding of the specific tasks that an individual must complete to perform his or her occupational duties as well as an assessment of whether there is any functional impairment that would preclude the individual’s capacity to complete such tasks. Because psychiatric training is focused on establishing an accurate DSM diagnosis and on providing appropriate treatment, most psychiatrists lack adequate skills, training, and education necessary to perform an assessment of functional impairment (also known as a functional assessment). While DSM 5 is a useful means of categorizing mental disorders and can be used to guide appropriate treatment, it is far less useful as a guide to functional assessment.

Endorsement of disability by a physician has many consequences. Some of these consequences can be beneficial, but there are also negative unintended consequences that can ensue.

Unintended negative consequences of disability:

• Decline of mental health and mental functioning

• Negative economic, psychological, and social effects of unemployment

• Role duality resulting in ethical and legal risks for the treater supporting disability rather than recovery and health

• Loss of identity as working individual

• Loss of life structure conferred by regular participation in work activity

• Disruption of the connection between work and reward

• Mental and physical deconditioning due to inactivity

 Long B, Brown AO, Sassano-Higgins S, et al. 

A complicated case of psychiatric disability

This article discusses the risks of supporting versus withholding support for a patient’s disability claim and six key definitions psychiatrists need to understand when they are asked to support such a claim.

Disability: Overview of Concepts Psychiatrists Need to Know

For the Committee on Work and Organizations, Group for the Advancement of Psychiatry

Bob, aged 50 years, worked as a factory manager for a large corporation but had problems getting along with peers and managers. Ultimately, he was fired for initiating safety policies without consulting with his supervisor and mandating compliance in his subordinates, who complained, leading to his termination. In his spare time, Bob renovates and sells (ie, flips) houses.

He went to his psychiatrist because of PTSD symptoms that he alleged were caused by the harassment he was subjected to and to wrongful termination by his employer. He wants his psychiatrist to complete his forms for disability. Bob had been discussing his problems about getting along with coworkers and superiors but said that he had finally “realized that the issue is my job. I’m always stressed and working full time has eliminated any space to work on myself and decompress. I just found out that I’m eligible for permanent disability with full pay based on my tenure-isn’t that wonderful?”

If this was so wonderful, then why was Bob’s psychiatrist filled with countertransferential dread? The concept of patient-defined disability seemed problematic. Work was indeed a source of ongoing angst, but Bob had been employed for years. Even if his current work environment was truly damaging, he was clearly capable of performing another substantial job, if not presently, then at some point in the future.

Patients who confess to struggling at work feel differently than patients who request disability. As the psychiatrist’s countertransference reaction revealed, the problem is one of role reversal between the treater and patient. Patients do not make functional assessments on themselves, professionals do.

If a psychiatrist determines that a patient is profoundly functionally impaired as demonstrated by the patient’s report of symptoms and the manifestations thereof, such as difficulty performing job tasks, evaluation for disability is the next step. The disability evaluation should be performed by a third-party mental health professional, as the treating psychiatrist has an inherent conflict of interest: his or her task is to advocate for the patient’s mental health, not disability compensation-to listen and understand, to demonstrate empathy, and to alleviate suffering. The task is also to instill hope and confidence, and to restore functioning. In many cases, deeming a patient “disabled” can be highly counter-therapeutic.

But what to do when the patient says that he needs disabled status? When, despite your professional opinion, the patient is convinced that work is not, in fact, a source of meaning and value and an excellent venue for working through relationship and life issues? When the patient believes that he is incapable of working, but you believe otherwise? Disagree or refuse his request, and the therapeutic alliance will be severely strained if not broken. The patient very well may displace his sense of work-related victimization, helplessness, and rage onto the provider, which can prove damaging for the psychiatrist as well as the patient.

What if a psychiatrist agrees with the patient’s professed disability and submits the required paperwork? This situation is no less problematic. Regardless of explanations to the contrary, the psychiatrist communicates that the patient is sick, ineffective, and at least temporarily broken and that he or she, as the treating psychiatrist, is incapable of healing the patient and therefore has given up. In the case of long-term disability, as with the patient above, the statement is more profound given its implied permanence. Thus, treaters have the options of either opposing disability, thereby damaging the therapeutic alliance, or supporting disability thus professing pessimism about the patient’s odds of recovery and removing work and its inherent value from the patient’s life.

The only reasonable option, particularly for long-term disability assessments, is to refer a patient for a third-party assessment. Occupational or forensic psychiatrists are an excellent option because they understand psychopathology and the functional and prognostic implications of disease. Unfortunately, this was not possible in the case that led our discussion. The paperwork specifically required that the treating psychiatrist deem the patient disabled, to the point of stating that third-party assessment would not be acceptable. The psychiatrist was handcuffed.

The psychiatrist, who did not agree that PTSD was the appropriate diagnosis for the patient, elected to provide fair warning, making explicit the dangers of filling out the paperwork. He warned that he would, in essence, be admitting defeat, and that the patient’s sense of trust in his psychiatrist and the field would waver. He explained that the patient’s core sense of brokenness and impotence would be confirmed, by a professional no less. He told the patient that removing work would remove a source of purpose, half of Freud’s “love and work” equation for mental health. Furthermore, he expressed confidence in his own ability to help the patient heal, his hope that this man would improve his maladaptive behavioral patterns and improve his ability to work effectively. He allowed the patient to make the decision, invoking informed consent.

What ensued was a therapeutic failure. The patient chose disability, and for 2 weeks, he felt significant relief. Shortly thereafter, he became cripplingly anxious, unable to plan and utilize his newfound free time effectively. Every unfilled minute reinforced his avoidance. He felt more broken than ever, separated from the herd of functional peers, a weak man who had admitted defeat, a man who no longer contributed to his society, his family, or his own well-being. Profound shame overcame him, followed by extreme anger misdirected towards the people and system he perceived to be driving his pain. Foremost among these abusers? His psychiatrist, who was “fired” less than a month later in favor of a “more supportive” physician down the road. The psychiatrist, viewed by the patient as adversarial, now experienced a profound feeling of impotence and guilt.

Although in some cases, a determination of disability is justifiable, necessary, and humanitarian, far too often, disability requests end in shared grief between patient and treater. This is a cautionary tale, but an avoidable one. Treating psychiatrists must continue to advocate for boundaries and avoid assuming a dual role of treater/evaluator with its inherent conflict of interest. Employers and insurance companies that insist on treating providers serving as disability assessors must be challenged. Patients must be encouraged to return to work, to have faith in themselves and their ability to recover, and to trust the system.

This continuing series of articles will explore the key issues psychiatrists must bear in mind when a patient requests disability. Given the ubiquity and complexity of this situation, the following topics will be explored in future issues:

• The overall concept of disability and definition of its six components

• Comprehension of the event(s), situation(s), and dynamics that precipitated the disability request in addition to any psychiatric diagnosis present in the patient

• How to perform a functional analysis, which determines, from the psychiatric viewpoint, whether a patient is truly limited or disabled from performing a specific job

• How to develop a plan that therapeutically addresses the problem(s) driving the claim of work incapacity, the goal being to facilitate the patient’s return to work

• An understanding of the risks inherent in assuming dual roles of disability evaluator and treater for the same patient; these risks are magnified if disability is denied or reversed and the patient asks the treater to assume the role of forensic expert.

 is Committee Chair, Work and Disability Consultant Private Industry, the Courts, and the Legal Profession; 

 is Department Psychiatrist, Boston Police Department, Consulting Psychiatrist, Boston Fire Department, Work and Disability Consultant, Private Industry and Government; 

 is Adjunct Professor, Department of Psychiatry, University of Southern California; 

 is Clinical Assistant Professor of Psychiatry and Behavioral Sciences, Chicago Medical School; 

 is Cotswold-Looney Fellow Emeritus, Group for the Advancement of Psychiatry.

What to do when a patient says they need disabled status, but you believe otherwise?

Author | Andrew O. Brown, MD

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