Disability: Overview of Concepts Psychiatrists Need to Know

THE REMAINING ARTICLES IN THIS SERIES

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

As in the case of “Bob,” whom you met in our previous article in the April 2019 issue, patients frequently ask psychiatrists to be “put on disability.”¹ 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.

Six key disability-related definitions

1) 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.

2) 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.

3) 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.

4) 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.

5) 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.”

6) 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

Risks of supporting disability claims

1) 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.

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

3) 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.”

4) 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.

Risks of withholding support

1) The patient may decide to sue.

2) The patient may decide to complain to the state medical board

3) The patient may write negative online reviews.

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

5) 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

• Social isolation and marginalization

• 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

• Loss of sense of meaning and purpose

• Disruption of the connection between work and reward

• Mental and physical deconditioning due to inactivity

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.

References:

1. Long B, Brown AO, Sassano-Higgins S, et al. A complicated case of psychiatric disability. Psychiatric Times. 2019;36(4):26-27.