Well, good morning, Dr. Malsberg.
How are you doing?
Oh, I'm okay. I think I'm going to have to be kinder and gentler moving forward rather than letting you edit out the acrimony.
The guests are hearing all the antagonism that I feel.
You mean the listeners? the listeners yes and our guests yeah well you know it's a different era just gotta adapt you know we gotta have more of a west coast feel and be gentle and huggy i
just want you to be i just want you to be nicer to me
You know, there's the concept of personas, right? With Jung. I'm not a fan of Jung. I don't know much about him other than his dalliances. But there's a sense that you're supposed to make different parts of yourself. And that's normal, right? Like the Greek persona, the large mask they would wear for the Greek tragedies so that the audience could hear and see which character they were.
Persona through which the sound comes out.
Yeah, exactly. And so I do think it is appropriate, especially in psychiatry, but across all of medicine, across all of society, for you to adopt certain personas in a healthy manner. That's natural to the situation. And I guess today we are going to be talking about not necessarily a persona, but a mode of thinking that I think a lot of psychiatrists and other clinicians get pretty nervous about.
Is that right? So are you saying you justify being mean to me because it's a persona?
No, that's not the persona. And I'm going to have to put on the professional persona for the audience.
The persona is being nice to me. Yes. Gotcha. Gotcha. Gotcha. Yeah. So what are we talking about today?
Well, my understanding is that we're going to talk about disability assessment and claims, which is an area that a lot of people are nervous about. Not exactly that you have to put on a persona for that with patients, but you certainly maybe need to think in a little bit of a different way. And I think part of it is actually understanding that you don't need to think too differently.
That actually to handle wrangle with disability, you can do quite a lot of the same stuff you always do, but you're just going to be a bit more specific with certain questions and thinking. So I guess that's step one. Don't panic is step one for disability assessment.
Yeah, I'm really excited to hear some of the things you have to say. I think for this podcast, I want to kind of go into kind of describing the different disability types. I know early on I had no clue. Like to me, it was just this big, giant lump of things. So it might be helpful to kind of go through the different types and what they mean.
And then kind of how you do the assessment, how you think about it. I know the area that I probably struggle the most on and I'm excited to hear you talk about is you have an intake and the first thing the patient says is they want some sort of disability paperwork and how to approach that assessment because it's very hard to do an assessment when you're just kind of first meeting someone on something like that.
Yeah.
Yeah, I'm going to rely on you to kind of bring up what the challenges are, right? Because I think if there's going to be one type of psychiatrist who's comfortable, this is going to be the forensic psychiatrist because it's bread and butter. But my sense is that training environments probably split the issue in terms of how they teach this to residents. They either ignore it entirely and say, listen, this isn't your job.
Send it to a forensic evaluator, which is not appropriate, by the way. You can hardly get a forensic evaluator for forensic cases. It's not accessible to your average patient. And then the other side is kind of like sign everything. You just whatever they want, give it to them. That's fine, which I think we really need to find a way to the middle. And that's the thing. Just like with many of the other topics we talk about, The obvious disability claims are not the difficult ones, right?
You see those, you sign them, or you don't sign them. It's the things that are kind of sitting in the middle that get a little bit more difficult. So hopefully we'll talk about that.
Yeah, maybe to start, should I kind of go through super briefly just the different kind of disabilities programs there are?
Yeah. So I guess that's kind of the prologue. When you're dealing with disability, the first question is, what kind of disability are we talking about? Because disability is a very broad term. And what we're wrangling with here is where psychiatric concepts interact with legal concepts. And if you're gonna answer those questions in an ethical and professional way, you do need to understand the rules. So ask yourself, under what rule set am I determining the presence or absence or degree of disability?
That's sort of question one when it comes to the disability claim. So let's go over some popular types.
All right. So the first major program is FMLA, the Family Medical Leave Act. That's a S. federal law that gives up to 12 weeks of unpaid job protected leave. So essentially, the person is not getting paid, but their job is protected at the end of it. It's eligible for pretty much anyone at any sort of large-sized corporation. I think it needs to have any employer that has more than 50 employees.
The definition is the person must have a serious health condition. So the condition must make it so the person can't do their essential job duties. So their specific job is what matters. Just from a direct quote from the FMLA, A serious health condition generally involves a period of incapacity. Incapacity means the individual is unable to work, attend school, or do regular daily activities because of the serious health condition due to treatment of it or from recovery of the condition.
And then another separate thing that clarifies a severe health condition is any sort of injury, impairment, or physical or mental condition that involves inpatient care or continuing treatment by a health care provider. And again, this is this applies to both the individual and a caretaker of another family member.
Yeah,
the short version is it has to be a serious enough condition medically that you can't do work, school, regular daily activities or that you're so occupied with the treatment that you can't do work, school, regular daily activities. You know, if you want the nuance, you got to read the rules. But that's the short version.
And I think it's important to clarify here because another program we'll be talking about. This is your you're not able to perform your job. What qualifies your ability to your job will be different if you're a construction worker or if you're a neurosurgeon.
Yeah, that's a bit of nuance that often won't be relevant, but sometimes can be relevant. So you sometimes need to look at that. Are you certain that it's specific to the job for FMLA? I mean, I think it's definitional because you generally only have one or two jobs, but I think it's just unable to work. There's a lot.
Well, I bring this up because we'll be talking about like SSDI, which the definition is not able to do any any job. I don't know if it's clarified, but in terms of how I think about it, it's the specific job that the person's at.
Okay, yeah, that does get us to something a little bit more. Sometimes you think of disability as what can this person do? Sometimes you think of disability as what can this person not do? In this case, the question that is being asked is what can this person not do? And as long as what they can't do is applicable to their current employment, that qualifies for FMLA. But that doesn't mean that you have to get into a very careful analysis.
All you simply have to do is you have to say, what are their tasks and duties? And is that being impaired by the current condition?
And we'll move on. And again, for FMLA, it's unpaid. And I think one of the things you're going to be talking about later is not it actually doesn't really matter if it's paid or unpaid because you should counter transference to how you experience the person or what you think about getting paid for not doing work should not come into these assessments. But we'll get to that later.
Yeah, simply follow the rules. So number one, know the rules. Number two, follow the rules. Number three, do a medical assessment. Anyway, that's going to be for later. Let's go over some other common types.
Then there's short-term disability and long-term disability. So these are temporary wage replacements. So usually the person is getting paid about half their salary. It kind of depends. This is provided by the employer or it's state mandated, but typically it's done through the employer. This isn't a legal – this isn't a law. Um, short-term disability has, is typically for three to six months. Uh, and long-term disability is when you kind of get greater than that.
Um, eligibility is when there is similar. It depends on the policy. So this one is going to be, uh, employer specific in regards to what the policy is kind of offering. Um, but typically we're talking about a sufficiently severe condition that makes it so they can't do their job duties. Um, Most policies require some evidence of total disability from doing their job. And typically, with short-term disability, the condition is expected to improve with treatment.
So it's not like you're kicking the can. You're expected to need a short time off to improve. Long-term disability, that begins after short-term disability ends. So you're talking about longer than three to six months. Yeah. It's the same thing. It's extended income protection for a long-term inability to be doing work. It can last years depending on the policy. Some policies will cap like mental health benefits at 24 months, but it really is policy specific.
Again, so for when you're looking for eligibility, you have to look at what that person's individual plan says. It's not like there's some universal law or rule that applies like it does for FMLA or SSDI.
Now, that's for the high SES set. How about for the low SES set or the government-based disabilities? So I guess I'll fill that in a little bit. There's also short-term disability claims that generally are embedded in state law. That's basically unemployment. It's different than unemployment insurance. It's disability insurance. Some states do provide this to have their own rule set. OK, and so that's something that you'll encounter more in the low SES because people are less likely to have a employer sponsored or self-sponsored self-paid disability plan for a short term.
There's also going to be some unique situations, especially if you're in a community mental health center where you're going to see disability claims that pertain to workfare. For example, somebody is on welfare, but state law requires that they engage in some level of job search or training, at least part-time, in order to continue receiving that welfare or that they want the welfare to continue past a certain point that there's a hard cutoff for people who are able-bodied.
Those can those scenarios can require a disability claim for some patients, and that's going to require you to read into those specific rules for your specific location.
Is that is that what George Costanza was doing with Vandelay Industries?
Kind of, but that's employment. That's unemployment insurance. There's also disability under state rules. Yeah.
All right, then moving on, the next set of agencies is SSDI, which is Social Security Disability Insurance, and SSI, which is Supplemental Security Income. These are federal programs for people who are unable to work due to medical conditions. For SSDI, SSI, I almost think of it as the same distinction between like, to me, like Medicare and Medicaid. SSDI requires work history and social security contributions. If you look at your paycheck, you'll see at the bottom, like a small amount goes to these kind of things.
Or a large amount. What?
Or a large amount. Anyway, go on.
That might be a West Coast bias.
No, it's federal. It's just it's just apperceptive. Anyway, go on.
That's true. SSI is needs based for individuals with low income. In regards to the disability, it must last at least 12 months or that you expect the person to pass away before that time.
It's effectively permanent. So the disability rules under SSI and SSDI are the same, actually. What's different is that for you to receive SSDI, you have to have accumulated Social Security credits, as you say, and it gives you basically a higher monthly payment. determine based on how much you've paid into the social security system compared to SSI, which anyone who's got a permanent residency can or citizenship can receive if they're sufficiently disabled.
In regards to who's eligible, I feel like that's going to be a big part of this podcast later going in. But essentially, it's a medically determinable impairment that limits work activities for at least a year. It's based off of the SSA Blue Book, and that has specific criteria requiring particular symptoms. And the focus is really on functional limitations or having marked functional limitations. Yeah. um so even if the person doesn't have a specific if if a listing is not met like they don't have a specific diagnosis if the functional impairment is so severe um someone can meet meet criteria and what they're really focusing on is whether a person can sustain full-time work with normal attendance pace interpersonal functioning um yeah
Yeah. And I think it's good to focus on the blue book because this is a publicly available document. And even if the type of disability that you're evaluating for does not follow those rules, most of them will not. Right. The SSA rules are very stringent in terms of the bar is high to meet that level of permanent disability. It still breaks down areas of work functioning that can be useful.
for you to read, to familiarize yourself with different levels of impairment and different types of impairment that can happen from medical conditions. By the way, we didn't discuss this beforehand, but should we talk about Americans with Disabilities Act's reasonable accommodation and also emotional support animals? Because I feel like it's kind of wrapped up into this and we better mention it.
It is. Let's put a pin in it. Let's kind of get through and we'll save that for the end. Or we'll do what we classically do and promise a second episode that'll be released in four months.
OK, sounds good.
All right. The last one that I kind of wanted to touch on is just workers comp. So workers comp is state mandated insurance providing benefits for work related injuries. So if someone gets this, it covers their medical costs. It covers their wage replacement. And depending on the longevity of the injury, potentially permanent disability compensation. uh the who's eligible it means that it was the injury was caused or aggravated by employment it does include uh physical mental things so for example let's say you hurt your back and you'd uh get ptsd through some through the injury um That would be covered.
And also mental-based ones. So if you just witnessed a traumatic event at your work and got PTSD, that would also be covered. So again, the psychiatric condition must be diagnosable and directly linked to a workplace exposure. So ordinary stress is not considered possible. it's not considered here. The stress must exceed a normal amount of job pressure. Uh, it requires the individual must timely report it. So you can't say like, you know, a long time ago I was, I witnessed an event and it must have clear medical documentation.
Um, So similar to the other one, yeah, so that's the gist of workers' comp.
Workers' comp, you often don't really need to get involved with too much. It's an interesting system. It comes from, I think, like Wilhelm or whatever, one of the leaders of Germany in the pre-modern era, just before pre-modern. I really don't know my European history. But it's, yeah, it's a state-established insurance system, basically, for workers. And most states have independent evaluators under the workers' comp system. You can become one.
You can take the test for it and do that kind of work if you'd like on the side or full time. And they also have a system of treaters who take workers' comp. So that's something to keep in mind. When someone's coming in asking about workers' comp stuff, they could be asking about the evaluation. or they could be asking about the treatment, and you don't really have to get involved.
What I would say about that is that you should just document and evaluate as you normally do for your specialty, and in our case in psychiatry, in an honest fashion. And that's going to be the fundamental first step to assessing disability. Do a regular or do a thorough, if you aren't yet thorough, do a full assessment Diagnosis and assessment for identifiable psychiatric conditions and level of functioning.
And document it. That's all you really need to be doing. What is the diagnosis? What are the impairments are the main questions.
Let's use this as a jumping point. Walk me through your general approach to someone who comes and asks for their disability paperwork to be signed. Walk me through what exactly it is that you do.
Okay. Is this an existing patient or is it a new patient?
I think it's important that we kind of go through both. But I think if we walk through a new patient, then we can adapt it at the end to an existing patient.
Okay. And just like we've been presenting on podcast, my first question is, what kind of disability would you like help with? Do you have any paperwork ready for this disability type? Do you have an attorney for this disability type? I want to know the operations of what I'm being asked about first because I can't really help until I know what the situation is. The second thing I'm going to say based on what they've asked me for in most cases is We're going to need more than one visit for this.
Or you might even say, we're going to need to schedule you for a specific visit for this. Or in the third option, unfortunately, sometimes based on what they're presenting with, you may have to say, I'm not able to help you with that. Sometimes there needs to be an assessment process. X amount of time after an injury. Sometimes a patient needs to be under your care already. Those are niche situations where you might have to say, unfortunately, you're going to have to go work this out for your attorney and get an independent evaluator.
What I can do is I can assess you. I can treat you for whatever problems you have now. I can put that in the medical record. And when the time comes, you can request those medical records with your attorney from the office. And then you guys can work on that. But otherwise, I can't do much more for you. So it just depends on the type of disability.
In the moment, how do you figure out which road to go down?
Well, you're going to have to know the rules of the types of disabilities. So if you don't know the rules of the types of disabilities, simply get as much information as you can from the patient about what they want, and then pick option two. Tell them, we're going to have to schedule a specific visit for this. And by the way, I would say that most typical disability paperwork is something that should be in the scope of practice for your average psychiatric practitioner.
I don't think it's appropriate to be outside of very specific things like workers' comp, putting this to some kind of, quote, specialist. Because the reality is most doctors are capable of assessing and making medical diagnosis and identifying the symptoms and the impairments. Because that's what's being asked of you. If you don't want to fill out further paperwork from that, Okay, that may be an office policy of some kind, but I think you should at least be able to do a somewhat more than superficial assessment, put it in the medical record, and allow the patient and whoever's helping them to go from there.
Oh, one caveat. There is a practice of certain attorneys that will send patients with basically boilerplate forms that they want you to fill out. You'll be able to tell that these forms are not government documents or official documents from some kind of a insurance company. These are forms that are generated by the attorney for you to basically do free expert work. I don't fill out those forms unless I think there's a very clear case and that the patient needs to get disability payments fast.
I won't fill out those forms. This can be a little bit hard to tell, but you just look at the forms themselves. Look for a code number on the form. Search it online. See if they're a standardized form from a government or insurance entity or if it's just the attorney has this list of things that they want you to give an expert opinion on without paying. OK, if it's the latter, I personally won't fill those out.
If they want an expert opinion, they can get an expert. If they want my opinion, they can get my medical records.
OK, so it's if I'm hearing this correctly, it sounds like for the vast, vast majority of cases, you say I'm willing to do a standard assessment and release my records. There are some cases that you're saying essentially that you're not comfortable filling out the paperwork, but that's a narrow scope. And then if it's legal documents that a lawyer kind of wants you to do independent assessment, that's when you would push back.
Yeah, basically. And just don't be afraid to buy time. And I know that's difficult emotionally because often patients, this very difficult field to navigate, patients have come to you and it's the first time they're seeing you and they need it like yesterday. Right. But you got wrong or something. That's not your problem. It's not your fault that the system is the way it is. You're not the one that waited X, Y, Z amount of time to engage with medical care.
OK, you are under no obligation to generate a bad opinion with an inadequate assessment. OK, you need to do whatever medical assessment investigation you need to do to get to a reasonable opinion before you can put anything down the paper with a signature. Don't write anything that you would not testify to under oath. OK, think about that. When you are writing things down, when you are giving opinions, it is only what you would be comfortable testifying to under oath in the court of law.
OK, so now walk me through the assessment.
Well, assessment is first, is there a diagnosable medical condition? So that's actually your normal assessment. And if you want to hear more about that and you haven't heard the episode on it, we have done episodes on psychiatric assessment. So go back to see those. But first, is there an identifiable mental condition or disorder under the rules of the DSM? I would follow the DSM rules. The DSM rules are probably the most organized rules we have around diagnosis.
Despite the DSM explicitly telling legalists not to use it as a manual or Bible, the law basically treats the DSM as the Bible. of psychiatric conditions. So know the rules under the DSM and follow the diagnostic rules and give an appropriate diagnosis. When you give that diagnosis, the diagnosis should not simply be, does this patient have it or not? You also want to establish a timeline. When did this particular disorder start?
When did they start meeting criteria and have they remitted at any point? OK, so the first step is identification of a medical diagnosis or diagnoses. And remember, you're physicians. You need to be testing for and considering other causes rather than primary mental disorders. You want to consider the contribution of medical conditions, substances, stressors, et cetera.
And maybe you'll agree with this. I would recommend people go back and listen to our intake episode. But the general gist here is... I have like a few go-to rating scales that help me kind of walk through whether I think someone has the criteria. So for depression, if I'm trying, you know, I have a very short amount of time for assessing whether I think they have depression or not, I go through the Madras.
And that's just kind of the one I've used so much that I haven't memorized at this point. But even early on, start, find a rating scale that you like. That maps well onto the DSM criteria and then use that as your assessment. And then I have one in my head for each individual diagnosis. Typically what I do is I ask a giant screener question with a high sensitivity.
If they trigger yes, then I'll go through a longer rating scale.
Yeah, there's a lot of different ways you can do that. You can call it using rating scales. You can call it using the DSM criteria too, right? Every DSM diagnosis has certain criteria that are absolutely necessary to make that diagnosis. You can start with that in the structured portion of your interviewing to determine whether somebody could even possibly meet criteria for that diagnosis at all. But again, listen to the assessment episode.
But the story that the patient comes with, their chief complaint, why now? That stuff will lead you down the road to determine what you should even be asking about specifically. So don't neglect that portion. So that's the diagnosis portion.
There's a few things you want to ask. And I think one thing that's helpful is you kind of I've heard you say before, like you're not your job isn't to be a super detective. You shouldn't be doing, you know, detective work to figure out if they really do or don't. But I'm curious. So, like, let's say it's on your intake and you're not sensing malingering, but you're doing the depression screen and they're maxing out on every single question.
How do you approach that?
Yeah, so that's something worth mentioning. Thanks for reminding me. Don't believe or feel or act like you have to be a forensic evaluator. You're still a medical evaluator here. You're just doing your regular job. You're going to see if there's anything that you and most professionals with the information that you have would make that diagnosis. OK. And if you don't feel like there's enough evidence for a diagnosis, you are not under an obligation to make a specific diagnosis.
Right. You can keep things unspecified, other specified adjustment based. It just depends on what you're seeing with the case. Now, what if you are suspicious that someone may be exaggerating? I don't think it's a good idea for people who are not experienced with malingering assessment, formal malingering assessment to call malingering. OK, that is. a risk on two ends. Number one, you yourself can potentially, in theory, though it's very low risk, I'm not saying it's low risk, it's very low probability, but there is a risk that you can be liable for calling someone a malinger, right?
They can say, I'm a real patient. I had a real disorder and you're calling me a malinger and that caused me some kind of a harm. So really be careful. If you're going to call someone malinger, you better know what you're doing. What is reasonable for most clinicians to do is to document any kind of suspicions about exaggeration or falsification. of symptoms. But if you're going to do that, you should say why.
OK, you should be able to say specifically why. For example, you might say, The patient did not show any objective signs of depression or anxiety and appeared to be perfectly comfortable and euthymic. Yet, he reported that every single depression scale was maximum severity. Given the discrepancy between his exam and the report, there is some suspicion for a tendency to exaggerate. You could do that. You could do that.
Do it to your comfort level. You don't have to document things like that, even if you notice them, but it's up to your comfort level.
Now, what about when you're picking up a lot of personality dysfunction um how would you screen for that especially you know as we've kind of talked about a lot of patients don't fit very neatly and almost no patients fit neatly into the dsm personality disorders um and it's not easy it's not like you mentioned like going through the the the dsm i can't with i can't say like are you interpersonally exploitative um Um, so how do you approach that?
First off, how do you approach, uh, I know it's a gigantic question, kind of ridiculous, but I do want to get you to answer it. Um, how do you approach assessing for those things briefly? And, uh, what do you do when a patient doesn't fit neatly into one of the, you know,
specific disorders? Yeah, no, it's a good question. Uh, I wouldn't deviate from your normal, uh, assessment. Okay. Whatever you normally do and whatever you normally document for personality, you should do it. And, uh, if there's enough, you know, the answer for most people is nothing. Well, then they better keep doing that unless they want to get to be better. They're going to have to practice and train their personality assessment.
Do what you normally do. And if whatever is presenting meets your clinicians, your personal clinician clinical threshold level for documentation, then you're going to start to document it. Right. If you can detect it and you can find the evidence to support your claim, you might say personality traits seem to be also at play here. Right. But personality is always active clinically, but it's also not sufficient to explain someone who is presenting more acutely.
OK, it's basically rarely sufficient to explain that. So I wouldn't try to attribute everything to personality. It's not plausible, especially if someone was functional before. Okay, you should look for more than personality if someone was functional before because personality is on the whole relatively stable compared to other mental conditions.
Okay. Now, in terms of screening for, let's say, anxiety, I think that's another tough one to assess for because, again, a lot of patients will say yes to everything. Can you walk me through how you would do an assessment for anxiety? Okay.
Yeah, I mean, this is really, let's keep it short because it's in the assessment episode, but you really can't rely on what people say to you on structured interview. A diagnosis is not what a patient tells you. A diagnosis is your whole thing. consideration of all the medical evidence. So try not to give leading questions or yes or no questions. Elicit story, elicit narrative. Ask what's changed, when, how, what were things like before, what are things like now?
Have people give you unstructured free-form narrative about the problem, its onset, and its development. That will give you far more information than any kind of structured questioning. Only do the structured questioning at the end if you feel like you're getting close to a very specific diagnosis. Okay. Great.
All right. Yeah, I actually cut you off from where you were about to talk about to ask these questions, so feel free to...
I can't remember where we are, but I think the next thing to say is that when you have a reasonable diagnosis or when you're reasonably sure that the best you're going to get is unspecified or other specified, then the next step is to get history and about the specific impairments. And if you can, can we review the Blue Book? And let's use the SSA Blue Book. Let's talk about, for example, mood disorders and look at the domains.
I don't know what they call it, but domains of impairment that are possible.
Let's take a second and let's look at the Blue Book criteria for disability. And again, this is applying to the SSDI SSI. But I think what you're kind of saying, it's a good framework for approaching these problems for all disabilities. That...
Sort of. Basically, they write out different domains or areas of functional impairment that you can apply to other types of disability to understand it, even if you're not going to be using the full rule set within the Blue Book. Unless, of course, if you are doing an SSDI evaluation, you would use this rule set. But let's give so I think we're going to be in Section 12 of the Blue Book.
That's the mental disorders. Right. And let's use 04, which is basically mood disorders. And if you go down to Section B, it starts to talk about areas of limitation.
So I guess one thing just for people to have a little bit of context, for each disorder, it gives very specific criteria for what they consider. And then in addition, each one has the functional impairment as a part of it. So almost it has criteria specific to whatever condition you're looking at, whether it's bipolar or depression. And then on top of it, it has the functional aspect.
And I think all the functional aspect remains essentially the same through each disorder. So why don't we... First talk about the for for the depression. Let's say let's say you're thinking depression. The first part is medical documentation of the depressive disorder, which is five or more of the symptoms. So it's essentially the same criteria as the criteria. And then in addition, it needs the functional criteria. And that's the part I think we're going to be talking about.
Yeah, and I'm not even saying that you have to be documenting this like it's a forensic report. What I'm saying is that if you're going to make your own medical determination about whether or not someone's disabled, then you should be considering and getting history from the patient about these kinds of areas. So what are the areas?
Yeah, I guess before we jump into it, I think this was helpful for me because it helps you understand it's not like it's just depression, therefore disability. It's these specific things that make it so that they can't function as well. that makes it so that they have the disability. So there's four areas. The first is understand, remember, or apply information. The second is interact with others. The third is concentrate, persist, or maintain pace.
And the fourth is adapt or manage oneself. And what's cool is in another area, they give examples of each, which I'll let you talk and then I can kind of walk through those different examples.
Yeah, no, I mean, really, there's not much to say. What's to say here is that this is not some super special assessment. You simply ask about an illicit narrative about these kinds of areas, right? You can prompt the patient about their job and what kind of difficulties they've been finding this stuff. And then as they talk and report things to you, your job is to basically say, does this seem to be reasonably connected to the identifiable disorder and the timeline or not?
And you're basically saying, is there a connection between the problem and the disorder?
Yeah. Another aspect that's super important, and as I mentioned earlier, is we don't let our countertransference get involved here. My thoughts or my politics or considerations of whether or not someone should have time off or whether or not... uh someone should be getting paid while they're not working or whether or not they're i dislike them because of their personality disorder simply should that should not be any sort of that should not be involved whatsoever with my assessment here um yeah and you need like it's not like oh this person's a jerk and like they're just trying to get a dime off the man that you you need to work out those thoughts uh because it shouldn't be involved with your assessments
Yeah. And on the other hand, you shouldn't be like, oh, you know, it's just a big corporation. You know, they owe the little guy stuff. I should just give them what they want. They're suffering. Right. There's positive countertransference to all stuff, too. Look, use the rules, understand the rules. You know, there's this concept from Zizek that actually having rules is in a paradoxical way freeing. Right. Because the more freedom you have, the more uncertainty you have about how to act.
But in this case, if you can apply the rule set and just follow it, that frees you, in a sense, from the decision making. But for the countertransference, just like the general concept, you do need to be aware of your personal biases and your feelings and essentially withhold them. You've got to be aware of your own patterns and withhold them to be a good evaluator.
Yeah, I'm glad you brought it up because you do see both extremes of people being like, you know, you shouldn't be getting paid and not working. And then you see the opposite of like mental health is the most important thing. And if you need to take your two weeks off to recharge, like you can take things too far. Like we're supposed to be, your thoughts shouldn't be getting, your opinion shouldn't be getting involved here.
Why don't I go through some of the examples they give for each? So again, there's four different functionality criteria. First is understand, remember, apply information. So I'll just walk through the different examples. Learn and recall terms, instructions, procedures. Follow one or two-step directions. Describe work tests to others. Ask and answer questions. Recognize and correct mistakes. Solve problems, sequence tasks, and use judgment.
Next. Those are just examples, right? You might identify areas of difficulty that are not listed in the text. This text is simply to help you as a clinician identify possible areas of impairment. Go on.
Next one is interact with others. That's the header. Cooperate with coworkers and supervisors, ask for help, handle conflict, initiate and maintain conversation, understand social cues, respond to correction and feedback, avoid irritability, argumentativeness, and suspiciousness. Which, looking at this criteria, in residency, I don't think anyone followed all these things.
Yeah, you know, it's important to remember that you take patients as they come. OK, if somebody at baseline has more irritability or sensitivity, they are still protected under the law as an equal system. OK, so if they develop a dysthymic or major depressive disorder on top of that personality, yes, they could be impaired or disabled in a way that somebody without that personality would not be. You have to take the patients as they come.
You're just following the rules.
Yeah, and going back to what we actually talked about in our very, very early episodes, sometimes people have this, develop this idea through their work in the hospital that like, oh, if it's personality, then therefore they don't deserve whatever it is. If personality therefore explains all, personality disorders are in the disability criteria and it lists specific, I mean, we can talk about what it says under that section, but people can get disability based off a personality disorder.
Yes. In theory, you can just have a personality disorder and get SSI. So it is a medical condition.
I'll keep moving on. Concentrate, persist, and maintain pace. That's the third functionality criteria. Begin and perform tasks consistently. Maintain pace and complete tasks on time. Ignore distractions. We don't do a good job of that. Transition between tasks without disruption. We don't do a good job of that. Work near others without interference. Maintain routine and attendance. Work full days without excessive breaks. The last one is adapt or manage oneself.
The examples are respond to workplace demands, adapt to changes, manage symptoms, distinguish acceptable from unacceptable performance, set goals and plan independently, maintain hygiene and appropriate attire, recognize hazards, and take precautions.
Yeah. So let's talk about specific identifiable characteristics of a major depressive episode that could be reasonably applied to these domains. OK, understand, remember and apply information that can obviously be impaired by poor concentration. Right. That poor concentration could also be affected by, let's say, ruminations, negative thoughts about oneself. Right. That could both both of those things could theoretically apply to the ability to understand or apply information, interact with others.
Right. Irritability related to a major depressive disorder or, you know, negative self-appraisal could impact or alter somebody's way of or willingness to interact with others. Okay, that could be an impairment. Concentrate, persist, or maintain pace. Obviously, concentration, core criteria of major depressive episode, that itself could impair this. What about maintaining pace and persisting? Obviously, low motivation, low energy, anhedonia uh type uh problems with a major depressive episode could impair this domain finally adapting or managing oneself right uh distinguishing between acceptable and unacceptable worse for example or maintaining your personal hygiene attire again can be impacted by a severe depression right and that could be causing some impairments as well and that can get more granular right if you are the it guy and you never talk to anybody in person and you work from home You might not be as impaired by your lack of showering.
But if you're in sales, that's a real impairment. Right. So you can't just look at the rules and read them. You do have to think a few steps ahead and be lively in your imagination and make connections that are there from the evidence.
And I'm just going to mention now, one thing that can help with this functionality assessment is the rating scale HUDAS, the World Health Organization Disability Assessment Schedule, which addresses a lot of these things that we're talking about. But I'm curious, how do you tackle getting these questions answered?
Yeah, well, I am a real fan of narrative because in my belief system, structured questioning is basically a rigid way of getting information, information that, in my opinion, can be more reliably and better obtained from getting narrative. So I'm very narrative based, but there's no problem with using standardized scales as well. Whether or not you're narrative, whether you're narrative or standardized questioning based, you just have to understand that your work is not done by simply getting a diagnosis and the functional impairment.
You need a rational connection between the two. You need to explain properly why one is connected to the other. Some of them are very obvious, like, for example, poor concentration attributable to a mood disorder will cause you to not concentrate well. Right. Some may require a little bit more explanation, but we really are getting into the area of documenting for the level of expert report. which is the art of using medical knowledge and expertise, but putting it into layperson language.
And you don't necessarily have to do that, okay, as a general clinician. You just have to have this thought process and get the history, and then you can output your conclusion, which is usually a signature on the line.
Now, I'm listening as a trainee or a new practitioner, and I would have loved to be able to jump straight into narrative. But the truth is, you need to understand the things before you can do the narrative assessment. Because I'm sure for you and for me, I could do the narrative assessment because these screening tools are built in my head. What I would recommend, and you might disagree, if this stuff is overwhelming...
What you do is do the rating scales with the patients and repeat them over and over and over. And then essentially what happens, I mean, I can give the Madras, for example. When I started using the Madras for my depression screening, I would ask the questions explicitly on it, you know, like the exact wording and then follow it. And then after a few months, that stuff's burned into my brain that I can actually get those answers to those questions without asking directly those questions.
So... I would recommend using the rating scales, doing them relatively robotically to start if it makes you comfortable, and understand that over time you'll get more and more comfortable and those things will get into your brain and it'll transform into something you can turn into narrative.
yeah no i i totally recommend that that's a great approach and frankly that's how i started out too um you do have to understand the crystallize and have the crystallized knowledge element of things before you can be adept in eliciting narrative that is true i've watched people just try to do narrative and it goes nowhere right you just get irrelevant material when i listening narrative does require you to redirect and prompt patients in a live way to get the right information.
And that is a skill that takes time. I think the next thing that we really should talk about is once you've agreed or once you've determined that a patient has a disorder and has disability, How much should you give? How long should you give? So this is something that then requires you to have more expertise. In order to do all of this, you have to be a proper psychiatrist.
You have to know all the expert stuff. So how you answer how long to give with time off is because you're asking, why am I giving time off? Why am I granting disability? Well, if it's SSI or SSDI, it's because they're permanently disabled. So it's forever. OK, technically, not exactly that there is nuance there. But for all the other types of disability, we give disability mostly because we anticipate that at some point there will be recovery and that recovery might happen on its own.
It might happen with assistance or it might happen with ongoing treatment. OK, so treatment is tied into disability. OK, if there's a treatable condition, you have to base your duration of granted disability based on your general knowledge and prognosis of the patient. OK, what do they have? Most people with the same characteristics, how long will it take for them to recover, at least partially? And what kind of treatments are necessary and how much time do those treatments need to take?
Mania. Mania, depending on severity, at least a couple of weeks usually, right? It takes two weeks for lithium to kick in. You're going to need a few weeks to get somebody stable. Depression. Well, it depends on the type of depression. It's such a huge category, right? But as we know, it can take three or four weeks to get to maximum effect, one dose of SSRI. You know, a psychotherapy usually takes, you know, a few weeks at least to really start kicking in.
It just depends on the condition and the treatment. So you need to ask yourself, what treatment is this patient going to get? What am I going to recommend, basically? And to what duration do I expect that they're going to have the level of disability needed for this particular type of grant?
Yeah, and I think this kind of goes back to what you're saying in that when I'm doing my assessment, I don't just stop once I have major depressive disorder, once I have bipolar disorder. To me, major depressive disorder is this enormous category of a bazillion different diseases. So during my evaluation on every single intake, I'm determining the longitudinal course and stability of the patient and the frequency, intensity, and duration of the episodes when they get depressed, looking at the residual symptoms between episodes, and I'm looking at their treatment adherence and response.
So we've talked, you know, go back to that intake episode, really getting that life history and in your mind having that picture of what, if I were to have mood on the y-axis and time on the x-axis, what that looks like, so that I have an understanding of what this person's depression looks like, what this person's bipolar looks like, essentially having their blueprint of what their mood disorder looks like to help me understand how I'm approaching and how I'm thinking about what treatments I'm going to be using and how long I expect treatment to take.
The second point I wanted to make that's so important is I've seen patients who they're following with a psychiatrist, they get put on disability, and they continue care as is. And to me, that logically just doesn't make sense. When patients are coming in good faith and they need disability, it's a time that... We have to, just on what we're saying, we're saying that the treatment as is is not working and we need to make a change.
So part of disability isn't just signing the paperwork or not signing the paperwork. It's developing a treatment plan. It's, okay, we're going to be taking this amount of time off. We're going to be switching to these medications. We're going to be using behavioral activation and we're going to be getting set up with a therapist. You need very specific plans to address and make sense of the time that you're choosing to take off.
Yeah, don't forget intensive outpatient too, right? Or even interventional measures for treatment. Just as if someone comes in and they're suddenly disabled from a broken leg, okay, even if they had some mobility limitations before, they're more disabled now than before. Your treatment plan should change. It should not still be what you had before the broken leg. You're going to want to cast a leg or fix it or do some surgery and then do some rehab.
Mental disorders are the same way. You see an exacerbation or new onset of a mental disorder. What's the treatment plan? It can't be the same thing that you're doing before. That's not good medicine. OK, even if the patient ultimately rejects your treatment recommendations, you should be recommending an adequately aggressive but reasonable treatment plan to try to get patients back. And that's the thing. Don't grant forever disability unless you think that someone is truly going to be permanently disabled.
Why? Well, actually, having a lot of time off work may sound good. OK, but if it's combined with a mental disorder, that may be a recipe for worsening that mental disorder in the long run. If you're not having somebody actively engage with a treatment to get them back to some reasonable baseline or improvement, you may essentially be facilitating the worsening of that mental disorder. Take mood and anxiety disorders, right?
These are things that rely on proper psychosocial functioning for people to recover. So if you are removing them from work, that might be a relief in one sense, but it also may be worsening the condition in the long run in another sense.
Yeah, and that's huge. And we talked about this in the Handling Difficult Situations podcast. But when you're doing this disability, you need to be considering the downsides of disability. With depression, with, you know, borderline – in good psychiatric management, a huge core concept there – and I know you always, like, laugh that it's inappropriate – is the, quote-unquote, like, get a life. it's important for the patient to have structure.
You want them to have, you want to improve their psychosocial functioning. It's important that they have a job. It's important. You want, these are people that as a result of their Their problems make it so that they push away from work and from things that stress them out. But you want to orient them towards ordinary life roles. And for a lot of people, work provides a structure that keeps them stable, even if they're miserable and they hate it.
I'm thinking of a friend who... He lost his job and he had like six months of paid leave. And his life fell apart because he would wake up at 11. He drank more alcohol. He started gambling a little bit more. Even though he didn't like his job before, it provided a structure that he didn't even think about. So it's like we all have fantasies of like, oh, if I wasn't working, God, I could wake up at 11.
I could catch up on all those books I've been meaning to read. But work actually provides a structure that's very protective for a lot of conditions. So when you're doing these disability assessments, you need to be talking to the person about the downsides of disability. And I also think we should talk a little bit about some patients are a little Pollyannish in regards to like, oh, I'm protected.
This won't ever impact my job or my getting a raise or anything. Yeah.
Yeah. yeah the harsh reality is that uh laws are just things written down in a book okay that we've all agreed to basically respect great quote yeah if modern events have not convinced you of this i'd like you to pay more attention laws are um only as good as the people who follow them right and so uh they can find ways to discriminate against you even if the law forbids it and in a way that cannot be detected or uh you know punched So be careful.
You know, even permanent disability is not really permanent, right? I've seen many cases where someone basically who had severe PTSD was misdiagnosed as having schizophrenia and then received SSI. And they were maybe in their 30s or 40s. Well, what happened? Well, four years later, as you would expect, the quote unquote schizophrenia completely remitted because it was PTSD. OK, and they were given a second generation antipsychotic, which also treats PTSD, and they got better.
And then the time rolled around for the renewal of the SSI and it wasn't granted. And suddenly they had a four year gap in their employment history. And they already were maybe not so employable. Okay. And then now suddenly they have no funding. Okay. They don't meet criteria for disability. They can't survive on just food stamps. They get homeless. Okay. So giving long-term disability will be, and can and will impact long-term employability, you have to really ask yourself, is this someone who is going to benefit?
Ask yourself, what are in the best interests of the patient in the long run, not just the short run? And how do you determine that? You have to plan the treatment recommendations.
Yeah, I'm glad you provided more of a low SES example because I was thinking of the high SES example of patients with these really competitive jobs having a gap or taking short-term leave. They're going to get passed up, and it's not the kind of thing that's going to be – there's no signs or objective things that the person can point to that they would have legal recourse.
But as a result of taking this disability, they're – going to get passed over for people who stayed and worked the whole time.
You know, I can talk about what I've seen also on the other end, you know, with forensic work. Even if you can mount a successful lawsuit after the fact, after a illegal firing, that's not a fun process. OK, my advice is don't go looking for trouble. Right. Most people fundamentally, they want to live a good life. They want to work a decent job where they feel effective or at least where they don't feel horrible and be functional.
OK, that's the dream. The dream is not to do nothing. Human beings fundamentally do not like to do nothing. They like to create things. They like to connect with each other and they like to generate. OK, that's the human trajectory. So try to get people onto the human trajectory.
Yeah, great point. And as you said, let's say that lawsuit does go through and they win. Every employer that they interview from now on is going to Google their name and up pops a lawsuit in their previous employer.
That's going to be a real issue. So, yeah, got to look out for the best interests of people. Don't withhold disability. Don't refuse to sign or assess for disability. That's part of the scope of practice. But do be careful when you give your treatment recommendations in the duration.
Yeah, and I hope we come off as an integrative podcast here. We're saying that disability is necessary and helpful and helps a lot of people get back on track. And when there's a mental disorder and it's appropriate, it really can make a huge difference in getting that person back on track and functioning. And the flip side is that there are downsides to it. And you need to look at both sides.
You can't sign every single paperwork for everyone who asked for it. And you can't deny every single person who asked for it on some vague principles. Yeah.
Now, let's talk briefly about the Americans with Disabilities Act and reasonable accommodations. Disability under the ADA is actually different than other disabilities because it's very, very easy to have qualifying, quote, disability under ADA because it's really more about being mistreated or discriminated against. So they wrote the law. so that you could qualify as having a disability even if you were perceived as having a disability and you didn't really have one.
So it's really more about preventing mistreatment. But they also want people to get what's called reasonable accommodations for a disability. Now, some people are going to come in and they're going to ask for reasonable accommodations based on mild anxiety and depressive disorders or personality conditions. The same principle applies. Even if this is theoretically possible under the law, you and the patient should ask yourselves honestly, how is this going to impact the patient's long-term trajectory within their current career and across careers?
Is this going to be a true benefit to them? Is the accommodation going to support, maintain and strengthen a symptom or impairment that should be treated rather than accommodated? Remember, the accommodation law is written for employers and for HR departments to wrangle with. OK, your job is not to just give accommodations. Your job is to treat the patient. Anything that an accommodation can be asked for could potentially be a treatment target too.
So you need to have an open discussion about that with the patient.
I'm really happy you brought this up because I'm thinking of a particular case of a patient who wanted the treatment accommodation of being remote full time. I was actually supervising this case. The patient struggled with anxiety and didn't have PTSD but reported trauma from work that made her want to avoid being in person. And, you know, there's a temptation to just sign that paperwork. It's like, oh, yeah, that'll help that person kind of work at home.
But as you're saying, it's like the person's anxiety and PTSD, that they're kind of signing themselves up for a lifetime of required at-home work. This person was really motivated. This person was really ambitious. They wanted a job. They wanted a raise. And I had to tell this, the person I was supervising, like, you have to have to talk about them that if they're going after these things, being in person is really important.
It's important for building connections, for building relationships, for the boss to see how hard you're working. Yes, as we were kind of saying earlier, there are legal things that say that a person can't be discriminated against as a result of their disability. But there's not going to be anything objective that they really can go after if they're going to be passed up as a result of someone who's going in five times a week and doing equal work as a person who's at home.
And by signing that paperwork, you're not working on addressing the anxiety and the PTSD. As we're talking about, a huge part of that is avoiding avoidance. And by signing that paperwork, you're promoting the avoidance.
Yeah. And that's where the emotional support animals come in as well. You know, regardless of your attitude towards these and whether you sign these letters, I would be less worried about that and would ask yourself, what am I actually medically recommending? Am I medically prescribing an animal? Do I have an evidence base to prescribe an animal? There are very few situations where I would do that. The only situations where I would do that is where I can see that an animal is clearly part of a behavioral activation plan.
Or really helps the patient continue to socialize or engage with a treatment. Seeing eye dog. You need the seeing eye dog to come to the clinic for psychotherapy. Well, that's an obvious one, right? But when it's less obvious, usually the request is a signal. for a important area of impairment, pathology that should be treated. And that's a opportunity to talk about that with the patient, regardless of your personal or clinic policy on these kinds of letters.
Can you be more specific? What signal is it pointing towards?
Well, it depends on the patient. We need to inquire with the patient, what does this animal help you with? right? Uh, what would happen without having the emotional support animal? What kinds of things do you experience and where do you experience them? Those are generally speaking, going to be, uh, anxiety based issues, um, that you can target in treatment with, uh, usually psychotherapy.
Oh, interesting. Cause I feel like most of the ones that I've seen have been like, uh, trying to kind of skirt certain rules, like emotional support animal, to be able to get them on an airplane. I remember one of my co-residents said someone, they signed a letter saying that they're allowed to pay their rent two weeks late.
Yeah, I mean, I really don't want physicians and other clinicians to be abusing their licenses that way. So I don't even, you know... Well, I comment too much more on that other than don't do that. But what I'm saying is that when someone comes in and asks for a medical intervention, I think we need to start with a good faith effort to determine whether a medical intervention is necessary.
And, you know, sometimes it is. OK, we can't assume that it's just trying to get one over the system or, you know, skirt certain rules. We're going to look for the pathology. And for everyone but your antisocial patients, when they see that you are genuinely there to be looking for moderate to severe or any kinds of impairing pathology and to treat that, then they'll understand. I think I have the faith that they'll understand that what your job is and your job is not a distributor of goods.
Your job is to help them get better.
Awesome. Any topics you want to touch on or you feel like is important that we kind of go over for this podcast before we wrap things up?
I think that pretty much covers it. I mean, people might have loose questions, but frankly, those are not easy to address on a podcast format. I don't think this is one that will need a second part, to be honest. I just can't imagine what could fill another hour.
Yeah, and I think we need to figure out what we want to do next. Maybe documentation. Maybe we got a few other things in the docket. We'll see.
Yeah. Well, like, comment, subscribe, and write down what you'd like to hear about into the future, I guess.
All right. Good talking with you.
Until next time.
Thank you.