Prevalence of Behavioral Health Concerns and Systemic Issues in Disability Treatment
2.4 Causality and Behavioral Health Concerns
Causality is a legal issue related specifically to tort law and the WC system. The legal standard for professional opinions of cause in civil legal settings is based upon “a more probable than not basis” (Kahn & Langlieb, 2005). Specifically, the issue of causality is one that behavioral health professionals are asked to address frequently both the workers’
compensation and tort legal systems. However, the issue of causality, particularly within the WC system, is at odds with the multidimensional behavioral health
(e.g., psychological and psychiatric competent evaluation and treatment approach) which is currently followed in the behavioral health field. The primary reason for the problematic opposition is that the WC standard follows an approach in which all injuries, illnesses, and impairments are considered workrelated when they are “caused or wors
ened by workrelated injury, even if the employee is predisposed to the impairment”
(Grant, 2005; Kahn & Langlieb; Melhorn & Ackerman, 2008). Therefore, the WC sys
tem follows an ordinal means of measurement delineating between only two categories of workrelated or not workrelated. There are no gradations between the two categories.
Moreover, the system does not consider the reported psychological disorder in terms of predisposition toward impairment, past development issues, or biological causes.
Consequently, there are many problems with this WC definition and its inability to trans
late directly to the highly complex assessment models employed with psychologists and psychiatrists. In a greatly simplified overview of the BH assessment model, BH profes
sionals must evaluate the person from multiple aspects of the person’s life, health, psy
chological, cognitive, emotional, and psychosocial factors to determine the appropriate diagnosis and then, treatment. In addition, BH impairment in functioning is multifacto
rial in nature. It is this lack of translation of legal terminology and an arbitrary categoriza
tion of work or nonworkrelated causation to the application of the BH treatment system that leads to a great deal of frustration and misconceptions (Grant). In order for a BH professional to attempt to answer the issue of causality, it is incumbent upon the other individuals involved in the disability process: employee/claimant, employer, families, coworkers, treating professionals, insurers, and attorneys to recognize:
1. The difference between impairment and disability.
2. What constitutes appropriate roles for the treating and evaluating professional.
3. The essential criteria of an accurate diagnosis, appropriate best practice standardbased treatment.
4. The expectation of setting RTW as a required treatment goal.
5. The high probability in remission of the majority of psychological disorders and reduction in objectively determined impairment.
6. The ultimate goal of the BH treatment process is to restore the person to one’s previous level of functioning (Warren, 2009).
This last aspect is of particular importance because if the person is to improve to one’s previous level of functioning , then it may potentially reduce the monetary award or benefits paid to the individual. In addition, because the actual cause of a true objectively determined psychological disorder is multifactorial in nature, the majority of BH disorders cannot always be readily connected with a single interac
tion, setting, event, or person. Moreover, many true objective psychological disor
ders do not occur/begin directly after a specific event which is often identified as a trigger for a disorder. Instead, the development of true objective psychological impairment in functioning is a complex process comprised of genetic, social, psy
chosocial, and biological ( biopsychosocial) factors that gradually converge across an indeterminate time period before a psychological disorder becomes apparent.
Thus, absolute determination from a behavioral health standpoint is not usually possible (Caine, 2003; Grant, 2005; Heilburn, 2001; Heilburn, Marczyk, &
DeMatteo, 2002; Heilburn, Marczyk, et al., 2003; Heilburn, Marczyk, DeMatteo,
& MackAllen, 2007; Heilburn, Warren, & Picarello, 2003).
Another issue that arises within legal causality is that all individuals involved in the disability determination process tend to use their own perceptions (accurate or inaccurate) to link a specific event as being the cause of the person’s psychological disorder. This is particularly true in the legal system. The inherent problem with this approach is that it does not always incorporate clear and objective data to support the perception or in some instances, the professional opinion. Consequently, when subjective information is utilized as “proof,” it further muddies the water regarding the causation issue (Grant, 2005; Melhorn & Ackerman, 2005; Warren, 2009).
In order for a BH professional to attempt to answer the legal issue of causality, the clinician must possess a thorough and competent understanding of the diagnostic pro
cess, how the correct diagnosis drives the selection of the appropriate treatment, and the emotional meaning that the individual has attached to the subjective symptoms s/he is experiencing. It is important to note that all parties, patients/employees/claim
ants, treating professionals, and attorneys frequently inappropriately subscribe cause to events and situations without the consideration of the necessary components of development, personality, and biological issues. Thus, this line of reasoning is often overly simplistic, circular in nature, and inaccurate. Most importantly, this ignores the significant complexity of the true development of a psychological disorder and that the majority of individuals with a psychological disorder still continue to function in life, including work (Grant, 2005; Grove, Zald, Lebow, Smitz, & Nelson, 2000; Melhorn
& Ackerman, 2008; Warren, 2009; Young, Kane, & Nicholson, 2007).
There are several factors that must be examined and evaluated by the BH profes
sional in order to complete a more thorough evaluation and to rule out potential treatment issues that are not psychological disorders and/or misperceptions, but may negatively impact on treatment outcome. These issues are:
• Primary gain. The person experiences relief with the symptom that helps to avoid an unconscious and internal conflict. It provides an acceptable excuse to avoid a situation. For example, a person with a severe headache is excused from going to work. The person has been having some dissatisfaction at work. Thus, the headache allows the person to avoid work. Thus, primary gain is an internal
ized motivation (Melhorn & Ackerman, 2008; Warren, 2009).
• Secondary gain. Any type of disorder may have a secondary gain component. In general, the motivation is externally based and is linked to obtaining or avoiding something. Examples of secondary gains can be increased attention from one’s spouse, avoiding a household chore or a jail sentence, or monetary awards. The key element is that the person is consciously aware of the motivation (Melhorn
& Ackerman, 2008; Warren, 2009).
• Lack of training and/or misperception. Frequently, person or professional will inappropriately associate an event as a cause of a BH disorder, but without full knowledge of the complex evaluative process. This is not done maliciously or with intent. It is simply due to a lack of knowledge or in the case of the professional, either lack of training or a bias in clinical opinion that is not supported by objective data (Melhorn & Ackerman, 2008; Warren, 2009).
• Malingering versus symptom exaggeration. Malingering occurs when a person knowingly and willingly fakes one’s symptomology for financial gain, such as in a lawsuit. It is not a psychological disorder. Instead, it is fraudulent behavior and one that may be criminal (Aronoff et al., 2007; Barsky, 2002; Iverson, 2007;
McCracken & Gatchel, 2000; Mittenberg, Patton, Canyock, & Condit, 2002;
Rogers, 1988, 1997; Rogers & Bender, 2003; Thompson, LeBourgeois, & Black, 2004; Warren, 2009; Wiley, 1998; Rohling, Binder, and LanghinrichsenRohling 1995; Scott et al., 2007, 2009).
• Symptom exaggeration is a conscious act. Although symptom exaggeration can be a component of malingering, it does not automatically equate to malingering.
For example, a person may exaggerate one’s symptoms because of wanting assistance with a problem and fearing the concern will not be taken seriously without consciously faking one’s symptoms. Instead, the individual may exag
gerate one’s symptoms as a means to ensure help is obtained for the concern. If the concern is objectively determined to exist, then, the professional will need to explore whether the exaggeration is simply an exaggeration or if it is a willful intent to purposely mislead the professional and the concern does not exist. The latter is an example of Malingering. (Aronoff et al., 2007; Barsky, 2002; Iverson, 2007; McCracken & Gatchel, 2000; Mittenberg et al., 2002; Rogers, 1988, 1997;
Rogers & Bender, 2003; Thompson et al., 2004; Warren, 2009; Wiley, 1998).
Because empirical research has revealed that there is a higher rate (30–40%) of symptom exaggeration and malingering with disability concerns due to motivation for a favorable outcome, it is imperative that all BH professionals evaluate for these types of issues (Aronoff et al., 2007; Iverson, 2007; Mittenberg et al., 2002; Rogers, 1988, 1997; Rogers & Bender, 2003). Moreover, the AMA’s Guides to the Evaluation of Permanent Impairment (AMA, 2008) require this as a part of the BH evaluation.
• Denial of a BH disorder. In our society, there is still a stigma of having a psycho
logical disorder. Thus, it is frequently difficult for some individuals to openly acknowledge the possibility of a psychological disorder. Instead, the person is likely to attribute the symptoms to another, more personally acceptable situation. This is a facesaving mechanism on the part of the involved person (Bagenstos, 2000).
It is essential to note that many BH symptoms are actually defenses used by the person for protection from one’s emotional distress. Because of this, the individual cannot typically provide objective and accurate descriptions, and a factuallybased explanation of the psychological concern. Thus, the person’s description is more likely to be subjective in nature and must be corroborated against other types of more objective data (Warren, 2009).
2.4.1 Professional Barriers to Objective BH Causality Determination
There are several additional issues that arise with professionals that further compro
mise one’s ability to infer with the BH causality determination process. These are:
• Incomplete or cursory evaluation and assessment of the individual. This occurs with the professional that does not follow all of the required components necessary to evaluate the person in a competent and comprehensive manner. Thus, the professional bases one’s professional opinion on incomplete professional data (Warren, 2009).
• Lack of clinical objectivity. In this instance, the professional is influenced by conscious or unconscious feelings. The professional then moves away from professional objectivity (Grove et al., 2000; Harding, 2004).
• Utilization of clinical heuristics. Heuristics represent clinical generalizations or shortcuts that a professional may use in either the evaluation or treatment pro
cess that are based upon incorrect assumptions (Harding, 2004).
• Differences in clinical opinion. This commonly occurs when professionals focus on select clinical information or data, while ignoring data that do not support one’s professional opinion or based on the lack of comprehensive synthesis of developmental, social, and biological factors (Grant, 2005).
• Potential loss of insurance. Because some systems such as the WC system only pay for workrelated concerns, this may leave a person without health insurance to pay for treatment. Thus, the individual may be inclined to claim that the condition is workrelated. At the same time, the professional may feel a quan
dary either in not treating the person or in opining that the concern is related to the workplace (Grant, 2005).
• A professional desire to not upset patients and referral sources. Most profes
sionals want their patients as well as referral sources to be happy with them.
Therefore, the professional may experience a wish to avoid conflict. In this circumstance, the professional may avoid issues and comprehensive evaluation as well as not stating the objective data findings clearly as a means to “keep everyone happy.” However, this greatly decreases the professional’s integrity as well as substantially degrades the credibility of the professional’s opinion (Warren, 2009).
• Lack of routine assessment of symptom exaggeration and malingering. In the evaluation of symptom exaggeration and malingering, many professionals are quick to avoid a comprehensive assessment of these issues because of the dis
tasteful nature of having to note that a person is purposefully misrepresenting the severity of symptoms. It is important to note that the current American Medical Association’s Guides to the Evaluation of Permanent Impairment (AMA, 2008) require the professional to evaluate for symptom exaggeration and malingering as part of the evaluation for any reported BH impairment in functioning. It must be noted that neither symptom exaggeration nor malinger
ing is not something that a professional can simply opine based on clinical opinion alone. Instead, it takes careful, comprehensive evaluation and includes looking at overall patterns across objective, standardized psychological tests (Aronoff et al., 2007; Iverson, 2007; Warren, 2009).
• Medicalization. This occurs when a professional identifies everyday situations, events, and occurrences and inappropriately mislabels them as medical or psychological disorders. Medicalization is at the heart of separating
psychosocial issues from true objectively determined psychological disorders.
Examples of psychosocial concerns are “stress,” job dissatisfaction, workplace conflict, and relationship discord, which may aggravate a psychological disorder , but are not actual psychological disorders themselves. The DSM does not have diagnostic criteria for psychosocial concerns. Instead, they are noted in the multiaxial diagnostic system (e.g., Axis IV). Importantly, psycho
social concerns are those issues that the majority of individual experience in the course of everyday life. While they may cause situational distress, they are not currently accepted as being a recognized psychological diagnosis.
Moreover, if a professional artificially separates a psychosocial concern from the biopsychosocial model but, ignores the contribution of these other com
plex aspects then this should be viewed as a deviation from current practice standards (Barsky & Borus, 1995; Warren, 2009, Warren, 2003).