A Complicated Case of Psychiatric Disability

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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?”

Countertransference

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.

Knowing the consequences

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.

A quandary resolved

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.

Conclusions

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.

Disclosures:

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