Prevalence of Behavioral Health Concerns and Systemic Issues in Disability Treatment
2.5 Causes of Iatrogenic Behavioral Health Disability
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).
2.5.2 Treating Professional Causes of Iatrogenic Disability
Treating professional iatrogenic disability is caused by one of two ways (1) injury occurs through overt action by the professional, such as prescribing the wrong medication and a negative reaction is experienced; or (2) by the TP provides infor
mation that conveys the message that the person is disabled or that the workplace is the source of the individual’s concerns (ACOEM, 2006, 2008; Aronoff et al., 2007; Norquist & Regier, 1996; Robinson, Gatchel, & Whitfill, 2005; Schultz &
Gatchel, 2005; Talmage & Melhorn, 2005).
It is essential that comprehensive mental health professional care must encompass a deeper understanding of how the label of disability generally introduces a clinical bias on the part of the professional that may interfere without considering other types of data that do not support a clinical conclusion of permanent impairment in function
ing. Moreover, when a professional conveys to the individual that a diagnosis equates functioning impairment, it is quite possible for this to become a selffulfilling proph
esy, leading the person to strongly identify with the disability role and believing that one is unable to function actively in life. This can lead to iatrogenic disability caused by incorrect information and assumptions. The importance of the professional taking a broadview approach to facilitate understanding in the individual being evaluated and treated as to what choices the individual can make, how a diagnosis may or may not impact on one’s life, how treatment will be structured to help ameliorate any cur
rent impairment, the inclusion of a RTW goal as a required part of the treatment process, and most importantly, how to resume living an active life – despite a psycho
logical diagnosis – are critical components in the treatment of BH health concerns (ACOEM, 2006, 2008; Aronoff et al., 2007; Norquist & Regier, 1996; Robinson et al., 2005; Schultz & Gatchel, 2005; Talmage & Melhorn, 2005; Warren, 2009).
2.5.3 Employer Contributory Factors to Iatrogenic Behavioral Health Disability
The employers also play a role in the creation of iatrogenic disability. Employers need to be aware that without appropriate training, employees, supervisors, and administra
tors alike are likely to flounder. This can create a workplace where expectations and standards are not conveyed or that there is inconsistency in how employees are treated.
Moreover, this stance causes confusion and frustration to occur and without an ade
quate means in which to address BH workplace concerns appropriately. Thus, job dissatisfaction can quickly occur and impact on work quality and productivity.
Moreover, this can be compounded by supervisory evaluation of poor workplace performance (DMEC, 2008, 2009; Kahn & Langlieb, 2005; Warren, 2009).
It is essential for employers to have workplace policy for both physical and BH concerns. It is still common for employers to have a workplace policy for physical concerns only. However, this leaves both the employee and employer in a poor position
to address BH issues when they arise (DMEC, 2008, 2009; Kahn & Langlieb, 2005;
Warren, 2009). For example, presenteeism may occur slowly before a person has a fullydeveloped psychological disorder. Presenteeism occurs when the individual con
tinues to work, but not up to one’s full responsibilities or potential. Over time, the employee’s workplace performance decreases substantially. Initially, this can be diffi
cult to distinguish from job dissatisfaction. Having a workplace BH policy in place and ensuring that employees are aware of the policy encourages employees to obtain pro
fessional assistance. In addition, it opens the door for employers and employees to discuss a health concern from a work perspective and to address a temporary work
place accommodation, if necessary. It should be noted that not all BH disorders require a workplace accommodation. As pointed out earlier, there are variations with a psy
chological diagnosis, with some people experiencing little change in everyday func
tioning, to some people experiencing moderate impairment, to the most extreme situations where a person is severely impaired. However, as the APF (2005) noted, this constitutes a crisis in which intensive care is required. In the worse cases, an individual may need to be hospitalized in order to be stabilized quickly. If an accommodation is needed, it should be linked objectively determined impairment in functioning as well as linked to specific job duties. Because the normal outcome of BH is recovery, it stands to reason that any accommodation will be temporary only. By having a BH policy within the workplace, both the employer and employee have a means to address a BH concern with consistency, so that all employees are treated in a similar fashion.
There is increased workplace stress occurring in the workplace (Wang, Demler,
& Kessler, 2002). This stress as well as interpersonal differences can lead to workplace conflict. While many employers have workplace policy regarding appropriate workplace behavior and the lack of tolerance for any workplace violence, this does not always address issues, such as communication difficulties with a supervisor or a specific coworker, or if the person is attempting to transfer to a different position or department because of these ongoing concerns. It is not always enough to simply have the people involved to sit down and discuss an issue. There are times when, despite taking this action, there are still interpersonal difficulties. A more winning strategy may be to take a commonsense approach in allowing an employee to transfer (if possible) to another department. Moreover, if there are sev
eral employees from the same department who transfer in a relatively short amount of time, an employer should address whether there is an issue with the supervisor. It is better for an employer to keep an employee, particularly an employee who has performed well in the past, than to simply ignore the workplace interpersonal con
flict (Kahn & Langlieb, 2005; Warren, 2009).
It is important for an employer to address workplace motivation issues and to recognize that not all negative motivation concerns, such as marital distress, lack of autonomy, work burnout, job dissatisfaction, job security, and disregard for workplace policies, are necessarily representative of psychological disorders. Instead, these can be representative of psychosocial issues. Psychosocial issues usually are feelings, events, or situations that are typical in everyday life. They are not objective psycho
logical disorders. Warren and Hubbard (2006, 2008) found that job dissatisfaction is a primary cause of negative workplace motivation.
It should be noted that inappropriate employee behavior tends to share the trait of workplace conflict. However, there are also instances where some inappropriate employee behavior is frank criminal behavior, such as with a serious threat to do harm to another person, theft, vandalism, or sexual harassment. In most instances, this type of behavior is not related to a psychological disorder and is under volun
tary control. Thus, it should be recognized by the employer and the workplace policy dealing with each of these situations must be followed (Warren, 2009).
2.5.4 Attorney Contributory Factors to Iatrogenic Behavioral Health Disability
The discussion of how attorneys can promote iatrogenic disability will be brief since there is an entire chapter devoted to attorneys and BH disability. Defense attorneys can promote disability by denying that the plaintiff has any concerns at all and indicating that the person is faking or greatly exaggerating. This is inher
ently upsetting to the person reporting problematic symptomology and may cause the person to become more entrenched. Conversely, plaintiff attorneys represent individuals who have been injured. Some plaintiff attorneys in legal proceedings may directly or indirectly note that the monetary value of the case is directly related to the severity of the injury. Thus, the person is encouraged to seek multiple profes
sional opinions to buttress the individual’s claim of serious injury. While both types of attorneys have roles in the disability process, both defense and plaintiff attorneys must take care to practice in an ethical manner, not just to win the case. Long after the case is settled, the person with the reported injury will have to live with both the positive and negative outcomes (Gold et al., 2008; Goldstein, 2003a, 2003b;
Heilburn, 2001; Heilburn et al., 2002; Heilburn, Marczyk, et al., 2003; Heilburn, Warren, et al., 2003; Heilburn et al., 2007; Melton, Petrila, Poythress, & Slobogin, 2007; Schultz & Gatchel, 2005; Simon & Gold, 2004; Van Gorp, 2007).
2.5.5 Insurer Contributory Factors to Behavioral Health Disability
The discussion of insurers will be equally brief since a later chapter will examine issues related to BH disability. However, insurers play a role in the iatrogenic BH disability process. There are a number of common issues that occur that serve to increase the probability of an adversarial interaction between the insurer and the claimant (Kemper, Tu, Reschovsky, & Schaefer, 2002; Hamm et al., 2007). These issues are:
• Lack of appropriate training for the case management of BH disability. By not providing appropriate training to case management employees and by not becoming educated in appropriate evidencebased treatment, this can directly cause arbitrary
decisionmaking. This and other factors will be discussed in Chap. 10 regarding the insurance industry and behavioral health disability.
• A systemic lack of standardization in the types of objective data required to make a decision regarding the BH disability claim. Each insurer has its own internal
ized system regarding the types of documentation required for the claim adjudi
cation process. Currently, some insurers request objective data, while others simply request the evaluation and treatment notes and make a determination based on the insurer’s internal criteria. Moreover, many insurers do not require the usage of DSMIVTR diagnoses and objective standardized psychological testing in the claim adjudication process. Because of this, frequently arbitrary decisions are made regarding the outcome of the claim, such as paying a claim that is unsubstantiated, but importantly, not paying a claim that may be substanti
ated with appropriate objective documentation (Hadjistavropoulos & Bieling, 2001; Hamm et al., 2007; Warren, 2009; Warren & Hubbard, 2008).
• Differences in how BH disability issues are handled versus physical disability claims as well as not recognizing comorbid health concerns. Frequently, despite changes in laws requiring the elimination of limiting BH treatment to ensure adequacy of care, some insurers still are limiting BH treatment. This is done by indicating that the insurer will only pay for an evaluation and then the TP must send the notes, so that the insurer’s utilization review professional deems whether any further treatment is necessary from the insurer’s perspective. This process is repeated when psychological testing services are requested by the TP. This is a slippery slope for the insurer because while an insurer cannot, by law, make treatment decisions, since this can be perceived as practicing without a license, this may result in this outcome unintentionally (Hadjistavropoulos & Bieling, 2001; Hamm et al., 2007; Warren, 2009; Warren & Hubbard, 2008).
Moreover, many insurers do not regularly assess for BH disorders with a physical disability claim. This is because many insurers still do not recognize the high prevalence of comorbid health concerns.
• Lengthy review process for both treatment and the claim itself. Some insurers also note that all BH treatment must be precertified. (Again, this is typically by a utilization review professional.) However, only after the TP has sent records and the precertification process has been completed, can any further treatment be given without the person having to selfpay for services. In one instance, this author had called an insurer who then directed the query to a BH claim triage professional (who worked exclusively for the insurer to approve clinicians’
requests for treatment). The BH professional approving treatment requests indi
cated that it was at least a 2week process before any decision about beginning professional treatment would be made. It was also noted that the process could take even longer than the 2 weeks. This is an unfortunate process that certainly does not allow for expedient professional care (Hadjistavropoulos & Bieling, 2001; Hamm et al., 2007; Warren, 2009; Warren & Hubbard, 2008).
• Lack of direct interaction with the TP. Many insurers require the TP to send records, but do not allow the TP to discuss the pertinent issues with either a case manager (CM) or the medical director to quickly address issues. An example of
this occurred when this author was requested to send all documentation to an insurer pertaining to individual with rapidly progressing Huntington’s disease.
The author contacted the insurer directly and asked to speak with the Medical Director to expedite the process. This request was denied the ability to talk by the CM with the medical director to discuss the pressing issues, later the medical director called the author directly. At that point, the disability claim was quickly approved (Melhorn & Ackerman, 2008; NBGH, 2007; Otto, Slobogin, &
Greenberg, 2007; Pransky, Shaw, Franche, & Clarke, 2004; Schultz & Gatchel, 2005; Talmage, 2007; Talmage & Melhorn, 2005).
• Lack of incorporation of scientifically based practice guidelines into the treatment and claim review processes. Currently, most insurers have not brought scientifi
cally based practice guidelines into the precertification and claim review processes.
This is curious since the insurer is making decisions as part of its internalized system. It would be quite easy to incorporate these types of evidencebased stan
dards as a means both to streamline the precertification and claim review pro
cesses and to ensure decision made within the insurance company that were in line with the scientifically based standards (ACOEM, 2006; Melhorn & Ackerman, 2008; Warren, 2009).
• The insurer employs psychologists or psychiatrists, but does not assess whether the professional has received appropriate training in disability assessment, evaluation, treatment, and prevention. Therefore, those professionals may make the same mistakes as other nonBH professionals. A primary issue with this for the insurer is that it makes the organization vulnerable to potential legal challenges, as has successfully occurred in the past several years (Warren & Hubbard, 2008).