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These 10 domains will help you determine if functional impairment exists, if it can be reversed, and if the patient can return to work.
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.xxTwo 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.
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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.
Domains of functional assessment
The specific mental functions that most commonly disrupt an individual’s capacity to sustain work capacity include:
1 Social competence and/or teamwork: This functional domain refers to the individual’s capacity to communicate, cooperate, and collaborate with peers, subordinates, or authority figures at the workplace.
2 Adaptability/flexibility: 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.
3 Conscientiousness/dependability: These relate to an individual’s capacity to be consistently relied upon to perform the duties that he or she is charged to perform.
4 Impulse and behavioral control: 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.
5 Integrity: 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.
6 Emotional regulation: 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.
7 Decision-making and judgment: 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?
8 Substance use proclivity: 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.
9 Risk-taking behavior: 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.
10 Cognition: If cognitive impairment is present, the specific job-relevant cognitive function that is disrupted should be identified.
Work-relevant functional impairment
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.
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LETTER TO THE EDITOR
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
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.