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Regular Article | September 01, 1999

An Approach to the Patient Seeking Psychiatric Disability Benefits

David Mischoulon, M.D., Ph.D.

Academic Psychiatry 1999;23:128-136.

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Disability BenefitsPsychiatric DisabilityDiagnostic Criteria

Dr. Mischoulon is Instructor in Psychiatry, Department of Psychiatry, Massachusetts General Hospital (MGH), Boston, Massachusetts. Address correspondence and reprint requests to Dr. Mischoulon, Department of Psychiatry, MGH, WAC 812, 15 Parkman Street, Boston, MA 02114; e-mail: dmischoulon@partners.org.

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Abstract

Psychiatric disability determination is a complicated task for the psychiatrist. With filings for disability benefits increasing, the task is becoming unavoidable. The increasing social cost of disability requires that psychiatrists learn how to respond appropriately to petitions for psychiatric disability benefits. However, there is a significant dearth of education on psychiatric disability assessment. The various disability programs are reviewed; criteria of disability determination and difficulties involved in making an assessment are examined. Characteristics of disability petitioners are reviewed, and practical suggestions are provided for psychiatrists on how to approach a psychiatric disability evaluation. Finally, recommendations for the inclusion of psychiatric disability assessment training in residency programs are outlined.

Figures in this Article

Psychiatric disability compensation, as well as all types of disability compensation, represent a basic act of societal justice, that is, to help out those who are too sick to work. Disability payments allow people with serious mental or medical illness to live in society; to meet their financial obligations; and to have the basic necessities of life, such as food, housing, and medical care. However, the increasing societal cost of caring for disabled individuals (a consequence of benefits paid and lost productivity) has sparked much controversy in recent years, as evidenced, in part, by the growing debate over welfare and Medicare reform in political arenas. Therefore, we sought to review psychiatric disability determination and compensation programs, and their impact on the psychiatrist.

Psychiatric disability costs society over $12 billion per year (1). About 10%—30% of Social Security recipients (more than 1 million people) receive psychiatric disability benefits, an increase of more than 50% in the past decade (2). About one-fifth of disability applicants claim a mental illness (3; Social Security Administration, personal communication, 1997). In 1996 there were 1,338,000 applications filed for Social Security disability benefits; of those, 645,800 (48%) were awarded benefits, of which 131,219 were for mental disorders (Social Security Administration, personal communication, 1997).

With the increasing number of disability petitions, an increasing number of psychiatrists can expect to be called upon to render a professional opinion about patient disability. Few psychiatrists, however, feel competent in this area, and many try to avoid this complex task (4). Psychiatrists need to learn how to respond appropriately to petitions for psychiatric disability benefits. Unfortunately, most psychiatric residency training programs do not include disability assessment in their didactic curricula (5), and supervising psychiatrists may be reluctant to address the subject during supervision of residents. This shortcoming may stem from a general unfamiliarity with the mechanics of a disability assessment and the countertransference issues that frequently arise when a patient presents with a disability petition. Consequently, the discomfort with disability assessment may be perpetuated to the next generation of psychiatrists, as the psychiatric resident may feel anxious, frustrated, and inadequately supported when called upon to perform a disability evaluation. This inadequacy may cause the resident to feel resentful or hostile, and present a threat to the doctor—patient alliance.

We will 1) review the psychiatric disability programs and limitations in the disability determination criteria, 2) examine the characteristics of disability petitioners; 3) provide guidelines on the approach to a psychiatric disability evaluation, and 4) outline suggestions for the inclusion of disability assessment in the curricula of psychiatric residency programs.

TYPICAL REASONS FOR A PSYCHIATRIC DISABILITY ASSESSMENT

There are several reasons for which a psychiatrist may be called upon to perform a psychiatric disability evaluation. These may include a request for medical leave of absence, a worker's compensation case, short- or long-term disability insurance claims or Social Security benefits, and requests for compliance with the Americans With Disabilities Act or with the Family/Medical Leave Act (6). This article will focus primarily on psychiatric disability determination in the context of an application for Social Security benefits, as this is the scenario most commonly encountered (3), particularly in the academic setting.

DISABILITY PROGRAMS

The different programs with which a psychiatrist should be familiar include the following.

1. Emergency Aid

These programs (formerly called Welfare or General Relief) are locally managed with variable eligibility standards and payment rates depending on the geographic location. Eligibility for these programs was originally determined by economic need, but a psychiatric or medical disability expected to last 60 or more days is now required to qualify. Benefits typically include a monthly stipend, and full coverage for outpatient treatment and medications (Department of Transitional Assistance, Boston, MA, personal communication, 1997).

2. Worker's Compensation

This is a program for workers injured on the job. Settlements are usually made in a lump sum allotted for medical care. No monthly stipends are involved. Medications are not included in the coverage. Benefits are subject to utilization review. In general, worker's compensation is difficult to obtain for psychiatric disorders (Office of Workers' Compensation, Boston, MA, personal communication, 1997).

3. Department of Veterans' Affairs

This compensation program, often referred to in the vernacular as "Service-Connected Disability (SCD)," is for veterans of the U.S. armed forces who have been disabled by injuries or disorders incurred in the course of military service (7). Benefits are based on degree of disability secondary to injury sustained while in service. For example, a veteran with 100% SCD would receive a greater monthly stipend than one with 50% SCD. Recipients also have full medical and psychiatric benefits, including medications.

4. Private Insurance Plans

These plans are primarily for medical or psychiatric care expenses. Monthly stipends and coverage may vary with different policies and companies.

5. Social Security Administration (SSA) Programs

The SSA was formed in 1935 for retired workers, dependents, and their survivors. The Social Security Disability Insurance Program (SSDI) was established in 1954, and today is the largest disability insurance program in the United States (3). About one-sixth of all Americans collect Social Security benefits (8).

SSDI is for disabled individuals who have worked a certain number of years and have paid into the SSA disability fund through the Federal Insurance Contributions Act (FICA) (9). Benefits range from 20%—60% of earnings, depending on number of years of work and average yearly earnings, although there is a limit on the maximum stipend that an individual may receive (10).

The Supplemental Security Income (SSI) program is for the aged, blind, or disabled with limited income and property (usually less than $2,000 in property), or for individuals who have not worked long enough to pay into the SSA, and so are ineligible for SSDI (9, 11). Benefits include a standard monthly nationwide stipend, which many states will supplement with added money (11).

Recipients of Social Security benefits usually have their medical care covered by the following programs.

Medicare

Medicare covers SSDI beneficiaries who are over 65, blind, or disabled (9, 12). The basic plan includes Part A, which covers hospital insurance. Individuals become eligible after 2 years on SSDI. Medicare recipients may also opt to pay an additional small monthly fee for Part B, which covers outpatient medical insurance, but does not cover medications. Psychiatric benefits include 190 lifetime days in a psychiatric facility, although individuals who have exhausted their lifetime allotment will be covered for a stay in a general hospital's psychiatric ward.

Medicaid

Medicaid is a federal state-shared health insurance program for SSI beneficiaries and other economically needy individuals (9). This program provides essentially unlimited care, including medications, but eligibility for specific treatments is subject to approval on a case-by-case basis.

It should be observed that an individual who is both disabled and poor may qualify for SSDI on the basis of disability, SSI on the basis of insufficient income and disability, Medicare (after 2 years on SSDI), and Medicaid (based on SSI or medically needy status) (9).

THE MECHANICS OF A DISABILITY PETITION

Although different compensation programs may have different systems for determination of eligibility, the principles of disability determination are essentially the same for all programs, that is, to answer the question of whether a patient can work. As a representative example, we will focus on the Social Security disability evaluation system, because it is the one most commonly encountered by psychiatrists.

A patient wishing to be considered for a Social Security disability evaluation for a mental disorder must file a claim with Disability Determination Service (DDS), which is made up of a disability evaluation analyst (a non-M.D. trained in disability evaluation) and a physician (though not necessarily a psychiatrist). The DDS will request a report from the petitioner's outpatient psychiatrist and use it to determine functional limitations and residual functional capacity. If the petitioner is turned down, an appeal may be requested within 60 days. In such a case, another DDS team will review the patient's claim, and may require a face-to-face meeting with the petitioner. The outpatient psychiatrist may be contacted again for further information (9).

If the review is unfavorable, the patient may request a hearing with an administrative law judge. If the judge rules against the patient, a review by the SSA appeals court in Baltimore, Maryland, may be requested. If the SSA court also renders an unfavorable verdict, the patient may obtain legal counsel and file suit in a federal district court (9).

An individual who is granted nonpermanent disability will be subject to a continuing disability review at least every 3 years (9).

CRITERIA OF DISABILITY AND DIFFICULTIES IN ASSESSMENT

The specific SSA guidelines for disability determination are issued every 5—10 years and involve specific diagnostic categories (9). These categories include organic mental disorders, psychotic disorders, affective disorders, mental retardation, anxiety disorders, somatoform disorders, personality disorders, and substance abuse (the last of which was recently eliminated). In addition to diagnoses, the assessment must include professional and social function, and should take into account the effect of medications and residence (13). The guidelines have varied over the years, and the reclassification or elimination of categories often results in litigation if many individuals lose their eligibility for benefits (14). For example, eligibility on the basis of substance abuse was recently eliminated, perhaps because of the belief that disability income may facilitate drug abuse, though this remains a controversial question (15—21).

To be considered disabled, an individual must be unable to engage in "any substantial gainful activity (i.e., which earns more than $500/month) by reason of any medically determinable physical or mental impairment or impairments that can be expected to result in death or can be expected to last for a continuous period of not less than 12 months" (9). The word "any" implies that the activity could be in a line of work other than the customary one (3).

Despite this straightforward description, determination of psychiatric disability is not simple (13), largely because determination involves a prediction of the future. Outpatient clinic assessments may not reflect the true extent of disability (22, 23). Disability may fluctuate with time, as seen in patients with bipolar disorder who may be very productive during a manic or hypomanic phase, but very unproductive during a depressed phase. Emphasis may be placed on subjective (nonmeasurable) rather than objective (measurable) impairments (24). Histories presented may not be corroborated, and patients may exaggerate or falsify their symptoms. Sadly, a few cases can cloud the fact that people do become disabled from psychiatric illness. Some practitioners harbor a professional bias against patients with certain diagnoses, such as dissociative disorders, fibromyalgia, and chronic fatigue syndrome (25, 26). Directing a patient to return to work prematurely may harm the patient or his/her co-workers, which can result in a malpractice suit (6). On the other hand, being labeled as disabled may permanently remove a patient from the workforce, often to his/her detriment.

Interpersonal factors can also render disability assessment difficult. Adverse interactions between clinicians and petitioners may complicate matters (e.g., if the patient presents in a hostile or entitled manner) (26). The treatment alliance may be disrupted when the physician disagrees with the patient's claim, or needs to question the patient's honesty (4). Conversely, the physician's role as patient advocate may decrease objectivity, as the psychiatrist may feel pressured to give the patient what he/she wants. This dilemma is especially common in long-term treatment relationships, in which the patient may expect that "of course my doctor will do this for me" (4, 6).

If the patient has a legitimate disability, such as a chronic psychotic disorder, the psychiatrist may feel sympathy. Frustration may arise if the patient is not disabled but chooses to be considered so because of unresolved passivity or dependency issues. Substance abusers may also cause frustration if they are viewed as creating their own problems. Finally, a psychiatrist may become angry or hostile if the patient exhibits antisocial traits and appears to be malingering for financial gain.

As a consequence of a psychiatrist's personal values, opinion may be affected (4). For example, a practitioner with strong beliefs about personal responsibility may be opposed, on principle, to disability seeking, and may view the patient as being rewarded for idleness (4). Conversely, a practitioner with more liberal beliefs may be inclined to sympathize with a disability-seeking patient. Psychiatrists need to be aware of their personal and political values and not allow them to cloud their clinical judgment.

Some practitioners may refuse to perform an assessment. However, the patient may then remind them that they are legally mandated to provide a report. Some may postpone the task, but in those instances, the agency will usually call the practitioner and obtain the information over the telephone. Some clinicians may provide a vague assessment; one study showed that about 50% of disability assessment reports are unsatisfactory (27). Finally, a psychiatrist may confront the patient by telling the person that the psychiatrist does not believe him/her to be disabled.

CHARACTERIZING DISABILITY PETITIONERS

Most applications for psychiatric disability benefits are rejected (Social Security Administration, personal communication, 1997), suggesting that many individuals claim a disability when they are not truly disabled. Disability petitioners are more likely than nonpetitioners to receive Axis II diagnoses (28), and their ability to express hostility seems to correlate positively with their obtaining benefits (29). Therefore, it is of interest to examine whether there is a characteristic component to disability seeking.

Studies of the demographics of disability petitioners (4, 14, 29, 30) found several characteristics in common: limited education and job skills, repeated job failure, unmarried status, history of unstable family relationships and abuse, poverty or economic insecurity, and migrant status.

Specific personality traits common to disability petitioners have also been examined. Perl and Kahn found disability petitioners to be dependent, passive, unmotivated, guilty, anxious, and prone to depression (29). Heiman and Shanfield found them to be rigid, obsessive, lacking introspection, and vulnerable to frightening episodes (4). Forrester suggested that disability seekers have an external locus of control, manifested by a tendency to blame their problems on others, and to view the disability determination process as arbitrary (31). Many disability petitioners also view themselves as being in an adversarial relationship with sociopolitical forces (4). The compensation war becomes, for them, a metaphor for class struggle, pitting the working class (represented by the disabled worker) against the capitalistic owner class (represented by the government, employers, or the insurance companies).

Disability seeking involves, for many, a primary gain (avoiding a difficult job situation), a secondary gain (being taken care of), and a tertiary gain (financial reward). The disabled individual may feel ashamed of his/her condition, but at the same time feels afraid to return to work (4). Disability seeking may also involve an unconscious neurotic element (the illness) and a preconscious exaggeration of symptoms (the weakness). Heiman and Shanfield thus paraphrase Descartes' "I think therefore I am" with "I think (I am disabled) therefore I am (disabled)" (4). These individuals appear to use their illness to rationalize their decline in productivity, and eventually become entrenched in "honorable" disability (29).

The following three vignettes represent different types of disability determination cases.

Case No. 1

A 24-year-old man, with bipolar disorder, antisocial personality traits, and a history of multiple arrests for car theft, was released on probation into court-mandated pharmacological treatment. He was treated with valproic acid, with excellent results. During the early course of the treatment, the patient applied unsuccessfully for Social Security disability benefits. The patient remained on "General Relief" for a few months and eventually returned to full-time work.

Case No. 2

A 49-year-old woman, with a history of dysthymia, claimed psychiatric disability for depression, despite mountain-biking three times a week. She obtained legal counsel early in the process, and was awarded Social Security disability benefits after a long court battle. Eventually, the patient began insight-oriented therapy to explore issues of motivation and dependency.

Case No. 3

A 40-year-old woman with severe posttraumatic stress disorder (PTSD) initially began a course of psychotherapy and medications, with fair improvement. Early in the treatment, she applied for Social Security disability successfully. Shortly thereafter, she terminated therapy but agreed to continue taking medications. Since then, her condition and motivation for improvement worsened significantly. Her compliance with treatment decreased, and the patient eventually became housebound.

In Case No. 1, the individual was not disabled but attempted to be labeled as such to obtain financial gain. In being rejected for disability benefits, he was able to find the motivation to return to full-time employment. This case also illustrates the impact that the cyclic nature of mental illness may have on the disability assessment. The patient presented in a hypomanic, but stable, condition during his evaluation; perhaps if he had presented during a full-blown manic or depressive episode, he might have qualified for disability compensation. In Case No. 2, the individual was not disabled but managed, through the resourcefulness of her attorney, to be judged disabled in a court of law. This patient seemed to be motivated by a desire to be taken care of and to assume no responsibility. Referral to psychotherapy was made in the hopes of helping her to regain the motivation to eventually return to gainful employment. In Case No. 3, the individual was legitimately disabled by her PTSD symptoms. However, the award of disability benefits may have contributed to her loss of motivation for improvement in her condition.

The cases presented here, and in the work reviewed, suggest that awarding disability benefits may result in adverse outcomes, which emphasize the importance of making an appropriate determination. Disability seeking may also represent a characteristic trait, particularly in those who are less disabled. While the selected cases seem to reflect a pattern of antisocial and dependent traits, we have observed, in our clinical experience, a broad range of character traits—for example, narcissistic and passive-aggressive, among others—that may impact on disability petitions. Further research may help clarify whether disability seeking is an independent entity, or a form of a mixed personality disorder.

GUIDELINES FOR OFFICE ASSESSMENT OF PSYCHIATRIC DISABILITY

The psychiatrist who is called upon to make an assessment of disability has several medicolegal obligations. First, there is an obligation to the patient, which is to certify disability only when appropriate, and to return the patient to work only when it is safe to do so. Second, there is an obligation to the employers and co-workers, which is to return the patient to work only when it is safe to do so (6).

The dual obligation of the psychiatrist may present an ethical dilemma, which arises when the treating psychiatrist is called upon to perform the assessment and report on his/her own patient. This scenario is very common, particularly in the Social Security system, which routinely solicits an opinion from the petitioner's psychiatrist. Strasberger et al. (32) reviewed the role conflict involved when psychotherapists must also serve as expert witnesses in cases involving their own patients. While the article focuses primarily on psychotherapy dyads, their observations are relevant to psychiatrists in general. The authors argue that when a psychiatrist acts as the patient's legal advocate, it often compromises the therapeutic relationship, regardless of the therapist's position (i.e., "for" or "against" the patient's wishes) in the case, and may cause harm to the patient (via therapeutic undoing) as well as to the therapist (who is placed at risk of legal liability). Consequently, the roles of therapist and expert witness are viewed as irreconciliable, and the authors argue in favor of keeping the two roles separate as much as possible. Our own observations of the difficulties in assessment illustrate how this ethical dilemma may be played out in the disability setting, and are essentially in agreement with Strasberger and colleagues. Nonetheless, because of the inevitability of this dual role, psychiatrists need to be comfortable with their dilemma, and not allow it to impede their task. A good understanding of the mechanics and criteria of a disability evaluation can help the psychiatrist to maintain a professional balance in such a situation.

The initial steps in an office assessment are to discuss the limits of confidentiality with the patient, and to obtain a signed release of information. The psychiatrist should obtain a standard history and, if indicated, perform a physical and neurologic exam. The mental status exam should focus particularly on concentration, attention, interaction, insight, judgment, and emotional state and lability (6).

It may be helpful if the psychiatrist understands the patient's job description and is able to assess specific work-related abilities (e.g., comprehension; ability to follow instructions; and gauge ability to perform repetitive, complex, and varied tasks at an adequate work pace). However, if the patient has been unemployed for a long time (as is often the case), there may be no specific job description to speak of. In such a case, the psychiatrist may be better off using the wealth of clinical information available, so that the agency can assess for itself what the patient might be able to do in a job setting. Other items to assess include the worker's ability to relate to and influence others, and to take responsibility. The side effects of medications and their impact on the worker should also be considered in the assessment (6). Other useful aids in assessment may include psychological, neuropsychological, and occupational therapy evaluations (6). There is controversy as to whether the treating psychiatrist should try to obtain collateral information from past psychiatric records, employers, and family, as this step enters the realm of a forensic investigation and may further complicate the treatment alliance (32). A psychiatrist who chooses to pursue such an investigation must take the time to discuss it thoroughly with the patient, and make sure to obtain written consent from the patient.

Once the assessment is complete, the psychiatrist must prepare the report. This task may take different formats (usually a letter or a form), but it has general guidelines (3, 6): 1) objectivity equals credibility, 2) diagnosis is not equal to disability, 3) symptoms and signs must be differentiated, 4) specific examples of function should be given, 5) only information relevant to the question asked should be given, 6) the prognosis with treatment should be emphasized, and 7) an opinion on disability need not be given. If the psychiatrist cannot be objective or obtain enough information, he/she may state this in the assessment form/letter, and offer a referral to an independent evaluator.

Dealing with patients who seek disability benefits requires tact to protect the alliance. When discussing the subject with the patient, it may be best to appear nonjudgmental and cautiously pessimistic. The psychiatrist may emphasize the difficulties involved in obtaining disability benefits, and remind the patient that the decision rests with the disability determination service or the courts, rather than with his/her psychiatrist. Some practitioners may fill out the assessment form in the presence of the patient. This approach saves time (and minimizes countertransference reactions, as the psychiatrist does not spend extra time on paperwork), and may embarrass the patient into truthfulness. If a claim is rejected, it is acceptable for the psychiatrist to commiserate with the patient, as a means of protecting the alliance. Arguments with the patient over disability should be avoided, however, and clinicians should consider termination if a patient tries to bully or threaten them.

If the patient obtains legal counsel in the disability petition, the psychiatrist may be asked to discuss matters with the attorney. To avoid misunderstandings, the psychiatrist should not use the patient as an intermediary, but rather should provide information requested directly to the attorney. This step may involve sending the attorney a copy of the patient's record, filling out a form, or writing a letter. Some psychiatrists may choose not to bill the attorney for the consultation, so that their objectivity is less likely to be questioned. Finally, psychiatrists must beware of attorneys who try to pressure them into saying things that are inaccurate.

DISCUSSION

Programs for the protection of the disabled are a necessary part of a civilized society (7). Published research data suggest that, by and large, the disability determination systems function in a fair and just manner. For example, a study by Massel et al. (23) suggested that, through elaborate testing batteries, most Social Security disability awardees are indeed unable to work. Likewise, a study by Rosenheck and colleagues (33) suggests that most people who are turned down for disability benefits are no more likely to return to work than those who receive benefits (presumably because they are too sick to do so). Also, the lack of disability benefits was shown to correlate with a greater incidence of homelessness in the mentally ill (34).

Nonetheless, the disability compensation system may be prone to abuse (35), and in some instances may do more harm than good, as the label of disability can encourage dependency and result in poorer treatment outcomes. The psychiatrist who knows how to do a competent disability evaluation plays a vital role in maintaining the integrity of the disability determination system, as well as the protection of the patient's well-being, which requires familiarity with the criteria of disability to ensure that benefits go only to deserving individuals, and only for the necessary amount of time.

There is, unfortunately, a significant dearth of education on disability assessment in psychiatric training. This is particularly serious, because psychiatric residents generally find themselves caring for sicker, lower-functioning patients, usually in the setting of a university hospital clinic or in a community center affiliate of their residency program. It is these very patients who are most likely to apply for disability benefits, given the severity of their illness and their lower socioeconomic background.

Therefore, it is critical that psychiatric trainees be better prepared for the task of disability assessment. Since there is a lack of empirical research and protocols regarding education in disability determination, we wish to propose a number of ways in which residency training programs might begin to address this topic. Residency programs should consider incorporating at least one or two sessions on disability determination into the didactic curriculum for psychiatry residents, beginning early in the postgraduate second year. Such a program could include a lecture covering the different disability programs and general principles involved in making an assessment (as have been outlined in this article). In addition, a session reviewing actual disability petition cases could be used to guide the residents through the process of a disability assessment. Residents who receive a disability petition from a patient should be required to meet with a supervisor who has some expertise in the area, prior to assessing the patient and writing their report. In particular, the supervisor should review with the resident the ethical conflicts involved in disability determination. If logistically feasible, supervisors might consider observing the resident during the disability assessment, so as to give feedback afterward.

Residents who receive such guidance will likely feel much more comfortable when called upon to perform a disability assessment. Above all, they will develop competence in an important and socially significant application of the clinical assessment skills that residency teaches.

It must be observed that our proposed approach to education about psychiatric disability determination lacks empirical data to substantiate its effectiveness. It does, nonetheless, represent an attempt to organize our thoughts about, and our approach to, disability determination, in a reasonable manner. Therefore, this article is not intended to be simply an instruction guide on disability but is meant to serve as a means for setting a framework for the development of further thought and education on this important topic. We hope that the suggestions provided in this article will make the task of dealing with the disability petitioner more comprehensible, and less intimidating, to both the beginning and the experienced psychiatrist.

ACKNOWLEDGMENTS

The author thanks Dr. Theodore Stern, of the Massachusetts General Hospital's Psychiatric Consultation-Liaison Service, for his critical reading of this manuscript, and his many helpful suggestions and encouragement.

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