Behavioral Health Disability (eBook)

Pamela Warren, Ph.D. is a licensed clinical psychologist specializing in occupational health psychology. She serves in the Department of Counseling Psychology at the University of Illinois School of Education and in the Department of Psychiatry at the University of Illinois School of Medicine. She maintains a clinical practice and provides professional consultation to medical and mental health professionals, employers, insurers, governmental agencies, and case managers on management and prevention of psychological disability. Dr. Warren

Preface 6
Acknowledgments 10
Contents 12
Contributors 14
Chapter 1: A Critique of the Behavioral Health Disability System 16
1.1 Overview of the Explosion of Behavioral Health Concerns 16
1.2 Problematic Factors That Complicate Behavioral Health Care 17
1.2.1 Comorbid Physical and Psychological Concerns 17
1.3 The Systemic Problems in the Treatment and Management of BH Concerns 18
1.3.1 The De Facto Behavioral Health Care System in the United States 18
1.3.2 The Contributory Factors of the Behavioral Health Treatment System and Insurers 19
1.3.3 Federal Agencies and the Incidence of Behavioral Health Disability 19
1.4 The Need for Improvement in Communications Among Professionals Involved in the BH Fields to Reduce BH Disability 20
References 21
Chapter 2: Prevalence of Behavioral Health Concerns and Systemic Issues in Disability Treatment and Management 24
2.1 Prevalence of Behavioral Health Concerns 24
2.2 BH Professionals Involved in the BH Disability Process and Problematic Issues 26
2.2.1 Problematic Inconsistencies in Professional BH Training 26
2.2.2 Clinical Psychologists 29
2.2.3 Physicians 29
2.2.4 Lack of Objective Assessment in the BH Evaluation Process 30
2.2.5 Problematic Selection of BH Treatment 31
2.2.6 Problematic Utilization of Inappropriate or Nonevidence-Based Treatment 33
2.3 Common Misperceptions That Occur with by All Professionals Involved in the BH Disability Process 34
2.3.1 Determination of Functional Impairment Versus Disability 34
2.3.2 A BH Diagnosis Is Automatically Equal to Impairment in Functioning 36
2.3.3 Behavioral Health Impairment in Functioning Is Permanent 37
2.3.4 Inappropriate Usage of Subjective Information Versus Objective Data for Behavioral Health Concerns 38
2.3.5 Over-Reliance on Subjective Information in the Diagnostic Process 38
2.3.6 Physical Disability Concerns Represent the Majority of the Disability Claims 40
2.3.7 Disability Concerns Can Only Be Physical or Behavioral in Nature, But Not Both 42
2.3.8 BH Issues Must Be Treated Differently from Physical Issues 42
2.3.9 Treating Professionals Are the Most Appropriate to Evaluate BH Impairment in Functioning Issues 43
2.3.10 BH Concerns Can Only Be Work- or Nonoccupationally Related 45
2.4 Causality and Behavioral Health Concerns 45
2.4.1 Professional Barriers to Objective BH Causality Determination 48
2.5 Causes of Iatrogenic Behavioral Health Disability 50
2.5.1 Personal Factors That May Contribute to Behavioral Health Disability 50
2.5.2 Treating Professional Causes of Iatrogenic Disability 51
2.5.3 Employer Contributory Factors to Iatrogenic Behavioral Health Disability 51
2.5.4 Attorney Contributory Factors to Iatrogenic Behavioral Health Disability 53
2.5.5 Insurer Contributory Factors to Behavioral Health Disability 53
2.6 Conclusion 55
References 55
Chapter 3: Effective Psychological Evaluation and Management of Behavioral Health Concerns 63
3.1 The Importance of Appropriate Psychological Evaluation of Behavioral Health Concerns 63
3.2 Current BH Evaluation Model 63
3.2.1 Relationship Status 64
3.2.2 Employment Status 64
3.2.3 Presenting Problem(s) 64
3.2.4 Personal Habits 65
3.2.5 Social History 65
3.2.6 Educational History 66
3.2.7 Past and Current Psychological History 66
3.2.8 Medical History 67
3.2.9 Mental Status Evaluation 67
3.2.10 Diagnostic Impressions 68
3.2.11 Summation and Treatment Recommendations 70
3.3 Additional Assessment Components to Add to the BH Evaluation 71
3.3.1 Military History 71
3.3.2 Legal History 71
3.3.3 Disability History 71
3.3.4 Evaluation for Potential Medicalized Issues, Malingering, and Symptom Exaggeration 72
3.3.5 Collaborative Communication and BH Referrals 73
3.3.6 Corroborating Documentation and Data 74
3.3.7 Objective, Standardized Psychological Testing 77
3.3.8 Appropriate Documentation Regarding Potential Limitations in Objective Impairment in Functioning 77
3.3.9 Drawing on the Strength of Scientifically Based Treatments of BH Concerns 78
3.3.10 Appropriate Treatment Goals (Including RTW) 79
3.4 The Behavioral Health Return-to-Work Process 79
3.4.1 Workplace Accommodations for Behavioral Health Concerns 80
3.5 Conclusion 81
References 82
Chapter 4: Assessment of Psychosocial Contributions to Disability 87
4.1 Introduction 87
4.1.1 Biopsychosocial Aspects of Disability 87
4.1.2 Subjective Risk Factors for Disability 88
4.2 The Assessment of Psychological States Leading to Disability 90
4.3 Psychometric Assessment and Disability 91
4.4 An Introduction to Psychological Testing Concepts 93
4.4.1 What Is a Standardized Test? 94
4.4.2 Validity Assessment 96
4.4.3 Malingering, Exaggeration, and Denial 98
4.4.4 Psychosocial Predictors of Poor Treatment Outcome and Disability 101
4.4.5 When to Administer Psychological Tests 104
4.4.6 Test Selection 105
4.5 Conclusions 105
Appendix: Psychometric Assessment Tools 106
References 113
Chapter 5: Psychiatric Issues in Behavioral Health Disability 119
5.1 Epidemiology and Prevalence of Psychological and Behavioral Health Concerns in Psychiatry 119
5.1.1 Psychiatry as a Medical Specialty 119
5.1.2 Psychiatry and Behavioral Health Disability 120
5.2 The Usual Treatment Process and the Role of the Psychiatrist 121
5.2.1 The Traditional Treatment Approach and the Paradigm Shift 121
5.2.2 The Usual Treatment Process 121
5.2.3 Avoiding Dual Roles 123
5.2.4 The Treating Psychiatrist as “Advocate” 124
5.2.5 Defining “Disability” 124
5.2.6 Challenges for the Treating Psychiatrist 125
5.3 Determining Current Psychiatric Functioning 125
5.3.1 The General Psychiatric Evaluation 125
5.3.2 The Psychiatric General Functional Assessment 127
5.3.3 The Psychiatric Occupational Functional Assessment 129
5.4 The Psychiatric Referral and the Occupational Referral 130
5.4.1 The General Psychiatric Referral Process 130
5.4.2 The Occupational/Workplace Psychiatric Referral 131
5.4.3 The Occupational Psychiatric Referral in Practice 131
5.5 Medicalization 132
5.5.1 The Process of Medicalization and Psychiatric Context 132
5.5.2 Overmedicalization in the Mental Health Disability Process 133
5.6 Symptom Exaggeration and Malingering 135
5.6.1 Malingering and the Disability Process 135
5.6.2 Malingering and Psychiatric Disorders 135
5.6.3 Psychiatric Response to Suspected Malingering 136
5.7 Patient Compliance Issues 137
5.7.1 Compliance and the Psychiatric Patient 137
5.7.2 Identifying Noncompliance 138
5.7.3 Treatment Approaches to Improve Compliance and Prevent/Reduce Noncompliance 139
5.8 Appropriate Documentation of Impairments and Limitations in Functioning 139
5.9 Treatment Outcomes: Strategies for Addressing Return to Work 140
References 142
Chapter 6: The Occupational Medicine Perspective on Behavioral Health Concerns 146
6.1 Epidemiological and Prevalence of Psychosocial and Behavioral Health Concerns 146
6.2 Discussion of Usual Care Treatment Process: Strengths and Weakness Within Occupational Medicine 147
6.3 Determining Current Psychiatric Functioning: Strengths and Weakness Within Occupational Medicine 148
6.4 Referral and Coordination of Treatment Considerations: Strengths and Weaknesses in Current Processes 150
6.5 Medicalization 151
6.6 Symptom Exaggeration and Malingering 152
6.7 Patient Compliance Issues 152
6.8 Appropriate Documentation of Limitations in Objective Impairment/Functioning 153
6.9 Treatment Outcome: Strategies for Addressing the Individual’s Return to Work 154
References 155
Chapter 7: Physical Therapy Treatment and the Impact of Behavioral Health Concerns 157
7.1 Epidemiological and Prevalence of Psychological and Behavioral Health Concerns in PT 157
7.1.1 Discussion of Usual Care Treatment Process 158
7.2 Determining Current Psychiatric Functioningand/or Behavioral Health Concerns, such as Fearof Reinjury: Strengths and Weaknesses in the Current Process 161
7.3 Referral and Coordination of Treatment 163
7.4 Medicalization 165
7.5 Symptom Exaggeration and Malingering 165
7.6 Patient Compliance Issues: Limitations and Strategies for Improved Management 167
7.7 Appropriate Documentation of Limitations in Objective Impairment/Functioning 169
7.8 Treatment Outcomes 170
7.9 Summary 172
References 172
Chapter 8: Vocational Rehabilitation Considerations for Mental Health Impairments in the Workplace 174
8.1 Introduction 174
8.1.1 Prevalence of Psychological and Behavioral Health Concerns in Vocational Rehabilitation 175
8.1.2 The Mental Health Conundrum: Impairment Versus Disability 177
8.2 Vocational Rehabilitation: The Treatment Process 178
8.2.1 Assessment and Appraisal 179
8.2.2 Career (Vocational) Counseling 180
8.2.3 Vocational Rehabilitation Plan of Service 181
8.3 Other Considerations in Vocational Rehabilitation 181
8.3.1 Malingering and Compliance with Services 181
8.3.2 Job Descriptions 183
8.3.3 How Are Essential Functions Determined? 186
8.4 The Dictionary of Occupational Titles 186
8.4.1 Temperaments 187
8.4.2 Procedure for Rating Temperaments 187
8.5 The O*NET 189
8.6 The Vocational Rehabilitation Tool Box 192
8.6.1 Case Management 192
8.6.2 Situational Assessment/Work Adjustment 193
8.6.3 Adjustment Counseling 193
8.6.4 Transferable Skills Analysis 194
8.6.5 Return to Work Services 194
8.6.6 Transitional Work Programs 195
8.7 Summary 196
References 196
Chapter 9: Case Management and Behavioral Health Disability 198
9.1 Epidemiological and Prevalence of Psychological and Behavioral Health Concerns 198
9.2 Co-morbid Behavioral Health and Physical Concerns 198
9.3 Defining Disability in the Behavioral Health Context 199
9.3.1 Types of Disability Benefits 200
9.3.2 Issues that Arise with Disability Benefits and Objective Evidence of Impairment 202
9.3.3 Family Medical Leave Act 203
9.4 Case Management Roles and Requirements in the Context of Treatment 204
9.4.1 General Problems Arising Within the Behavioral Health Claims Process 204
9.4.2 The Impact of Poor Documentation on Disability Claims 205
9.4.3 Objective Psychological Testing 206
9.4.4 Subjective Information 207
9.4.5 Assessment of the Behavioral Health Disability Claim 208
9.4.6 Assessment of the Treatment Being Provided 208
9.4.7 Psychosocial Concerns Versus True Psychological Disorders 210
9.4.8 Utilizing the Expectation of Consistency in Objective Impairment and Functioning 212
9.4.9 Patient Compliance Issues Within the Behavioral Health Disability 213
9.4.10 Symptom Exaggeration and Malingering 214
9.4.11 Collaboration Among Treating Professionals 215
9.4.12 Medicalization of Psychosocial Issues 216
9.5 The Return to Work Case Management Process in the Context of Behavioral Health 216
9.5.1 Workplace Accommodations and Return to Work Planning 217
9.5.2 Appropriate Roles for the Case Manager 218
9.6 Strategies to Address Weaknesses Occurring in the Behavioral Health Disability Case Management Process 219
9.7 Conclusion 222
References 223
Chapter 10: Behavioral Health and Disability Insurance: A Perspective 229
10.1 Important Definitions and Behavioral Health Disability Claims 229
10.1.1 A Simple Concept? 229
10.2 Overview of Social Security Administration Disability 230
10.2.1 Big Problem? Little Problem? 230
10.2.2 Workers’ Compensation (WC) and Behavioral Health Disability 233
10.2.3 A Private Insurer’s Overview of Behavioral Health Disability Trends 234
10.2.4 A Closer Look at Major Depressive Disorder 238
10.2.5 Disability Insurance and Disability Management: The Odd Couple 240
10.3 Common Problems that Occur with Behavioral Health Concerns 242
10.3.1 Bureaugenic Disability 242
10.3.2 Claims Adjudication 243
10.3.3 Disability Deception? 244
10.4 Strategies for Superior Management of Behavioral Health Disability Claims 245
10.4.1 Work Capacities and Job Demands 245
10.4.2 Controlling Risk 247
10.4.3 BH Risk Management Strategy 1 248
10.4.4 BH Risk Management 2: Transitions In and Out 250
10.4.5 Return-to-Work Planning 251
10.4.6 Incentives and Disincentives 252
10.4.7 Rehabilitation Benefits 253
10.4.8 Appropriate Determination of Impairment in Functioning 253
10.5 Protecting Productivity: A New BH Business Model 254
10.5.1 Employer Education 255
10.5.2 A Corporate Health and Productivity Strategy 255
10.6 Summary 257
References 257
Chapter 11: The Legal System and Behavioral Health 263
11.1 Causes of Action and Their Prevalence 263
11.1.1 Workers’ Compensation 264
11.1.2 Americans with Disabilities Act 265
11.1.3 Civil Rights Enforcement Under 42 U.S.C. 1983 and Under State Civil Rights Laws 266
11.1.4 Psychological Torts 266
11.1.4.1 Intentional Infliction of Emotional Distress 267
11.1.4.2 Hostile Working Environment (Sexual Harassment) 267
11.1.4.3 Posttraumatic Stress Disorder and Other Psychological Claims Rising from Traumatic Events 267
11.1.5 Disability and Health Insurance Claims 268
11.1.6 General Considerations Concerning Reporting of the Prevalence of Behavioral Health Claims 269
11.1.6.1 Stigma 269
11.1.6.2 Concentration on Physical Ailments 270
11.1.6.3 Failure to Diagnose Behavioral Health Concerns 270
11.2 What Works, and What Does Not Work, in Legal Representation of Persons with Behavioral Health Concerns 271
11.2.1 Plaintiff’s Lawyers 271
11.2.1.1 The Private Plaintiff’s Attorney 271
11.2.1.2 The Public Plaintiff’s Attorney 272
11.2.2 The Defense Attorney 273
11.2.2.1 Defense Attorneys Who Are Compensated According to Contract 273
11.2.2.2 Salaried Defense Attorneys 274
11.2.3 Treating Professionals 274
11.2.4 What Works, and Does Not Work, in the Legal System? 275
11.3 Determining Current Behavioral Functioning in the Legal System 277
11.3.1 The Legal Standard of Proof Concerning Scientific Evidence 277
11.4 Case Coordination and Coordination of Care 280
11.5 Medicalization of Claims 281
11.6 Professional Enabling 283
11.7 Symptom Magnification and Malingering 285
11.7.1 The Importance of Language 285
11.7.2 Symptom Magnification 286
11.7.3 Malingering 286
11.7.4 Other Reward Seeking Behavior 287
11.7.5 Control of Symptom Magnification and Malingering by the Plaintiff’s Advocates 287
11.7.6 Control of Symptom Magnification and Malingering by Defense Advocates 288
11.8 Facilitating Return to Work and Stay at Work Behaviors 289
11.9 Appropriate Documentation of Objective Impairment and Limitations of Functioning 290
11.9.1 Distinguishing Between Objective and Subjective Evidence 290
11.9.2 Impact of Objective and Subjective Evidence 291
11.10 Dispute Resolution Outcomes 292
11.11 Some Possibilities for an Improved Systemic Approach 294
11.11.1 Changes Lawyers Can Make 294
11.11.2 Disengagement of the Profit Motive from the Litigation Process 296
11.11.3 Beyond Professional Enabling 298
11.12 Conclusion 298
References 299
Index 302