Key moments, in order
Do not panic about disability. You do much of what you always do, just with more specific questions and thinking.
Training often ignores disability and says to send it to a forensic evaluator. That is not appropriate, and you can hardly get a forensic evaluator even for forensic cases.
Disability means a lot of different things, so question one is which rule set you are judging it under. Figure out what kind of disability it is, then read the rules, then apply them to this patient.
FMLA is a US federal law giving up to 12 weeks of unpaid, job-protected leave: no pay, but the job is there at the end.
For FMLA, the condition has to be serious enough that the person cannot do work, school or regular daily activities, or is so occupied with treatment that they cannot. Ask what their tasks and duties are and whether the condition impairs them.
Know the rules, follow the rules, and do a medical assessment. Each kind of disability has a rule set for deciding whether someone is medically disabled.
Short-term disability typically runs three to six months, and long-term disability covers longer. Eligibility depends on the policy, and some policies cap mental health benefits at 24 months.
Some short-term disability is embedded in state law. It is disability insurance, different from unemployment insurance.
SSI and SSDI use the same disability rules. The difference is that SSDI requires accumulated Social Security credits.
For Social Security disability, the real focus is whether the person can sustain full-time work with normal attendance, pace and interpersonal functioning.
Even when a claim does not use its rules, the Blue Book is worth reading: it breaks work functioning into areas that familiarize you with different levels and types of impairment.
For workers' compensation, the psychiatric condition must be diagnosable and directly linked to a workplace exposure. Ordinary stress does not count; it must exceed normal job pressure.
The main questions are what the diagnosis is and what the impairments are. Assess for identifiable psychiatric conditions and level of functioning, honestly, as you normally would, and document it.
First ask: what kind of disability do you want help with, do you have paperwork ready for it, and do you have an attorney for it?
You do not have to act like a forensic evaluator. You are still a medical evaluator doing your regular job, and most typical disability paperwork is within the average psychiatric practitioner's scope.
Be wary of attorney-generated forms: they are asking you to do free expert work. We do not fill them out unless the case is very clear and the patient needs payments fast.
Do not write anything you would not testify to under oath.
The DSM tells lawyers not to use it as a bible, but the law basically treats it as the bible of psychiatric conditions.
Asking "were you depressed?" is the worst possible screener. Use something like the MADRS, whose questions are linked to the DSM criteria, or ask a high-sensitivity screening question and go to a longer rating scale if it is positive.
The story the patient brings, the chief complaint and why now, tells you what you should even be asking about specifically.
If you are not experienced in formal malingering assessment, do not call malingering.
Personality is always active clinically, but it is rarely sufficient on its own to explain someone presenting acutely.
A diagnosis is not what the patient tells you; it is your consideration of all the medical evidence. Avoid leading and yes-or-no questions, and elicit the story.
The Blue Book's mental disorder listings judge function in four areas: understand, remember or apply information; interact with others; concentrate, persist or maintain pace; and adapt or manage oneself.
A diagnosis and an impairment are not enough on their own. You need a rational connection between the two: does the reported problem reasonably connect to the identified disorder and its timeline?
Your politics, your views on paid time off, or disliking someone because of their personality disorder should not be involved at all. Be aware of your own patterns and withhold them to be a good evaluator.
A personality disorder is a medical condition. In theory, a personality disorder alone can qualify someone for SSI.
For disability, connect symptoms to the specific job. Not showering may barely matter for someone who works remotely in IT and is a real impairment in sales.
The WHO Disability Assessment Schedule (WHODAS) can help with the functional assessment.
Use rating scales, fairly robotically at first if that is more comfortable. Over time you will get more comfortable and the questions will get into your brain.
Apart from SSI and SSDI, disability is given mostly because we expect recovery at some point, whether on its own, with help, or with ongoing treatment.
For depression, determine the longitudinal course and stability, the frequency, intensity and duration of episodes, and residual symptoms between them.
Disability is not just signing or not signing the paperwork. It is developing a treatment plan.
With an exacerbation or a new disorder, the plan cannot be the same thing you were doing before. That is not good medicine.
Do not grant forever disability unless you think the person truly will be permanently disabled.
Work provides a structure that protects against many conditions, so talk with the person about the downsides of disability.
Long-term disability can and will affect long-term employability, so ask whether this person is really going to benefit.
People fundamentally do not like to do nothing. They like to create, connect with each other and generate.
You cannot sign every form for everyone who asks, and you cannot deny everyone on some vague principle.
It is very easy to have a qualifying disability under the ADA, because the law is really about people being mistreated or discriminated against.
Your job is not just to give accommodations. Your job is to treat the patient, and anything someone asks to be accommodated could also be a treatment target.
A huge part of treating anxiety and trauma is avoiding avoidance. Signing paperwork that lets a patient avoid what they fear promotes the avoidance.
Ask what you are medically recommending and whether there is an evidence base. An animal fits when it is clearly part of a behavioral activation plan or helps the patient engage with treatment.
A request for an emotional support animal is usually a signal of an important area of impairment that should be treated, and an opening to talk about it.
Start with a good-faith effort to decide whether a medical intervention is necessary. Sometimes it is.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.