Meanwhile, extensive progress has been made in the understanding and professional treatment of mental disorders. Today, mental health conditions and psychosocial problems, such as job dissatisfaction, poor coping strategies and motivational problems, have been combined in the coined term behavioral health.
Overview of the Explosion of Behavioral Health Concerns
A Critique of the Behavioral Health Disability System
Problematic Factors That Complicate Behavioral Health Care
- Comorbid Physical and Psychological Concerns
It is thus essential for all professionals involved in the treatment and disability management processes to recognize the wider range of BH concerns, as well as to incorporate a biopsychosocial approach across professions. It has been noted that the current BH treatment and disability systems are major contributors to the current explosion of BH concerns.
The Systemic Problems in the Treatment and Management of BH Concerns
- The De Facto Behavioral Health Care System in the United States
- The Contributory Factors of the Behavioral Health Treatment System and Insurers
- Federal Agencies and the Incidence of Behavioral Health Disability
The SSA's (2008) actuarial data provide ample evidence of the substantial increase in BH concerns over the past two decades. Randomized controlled research has consistently shown a high prevalence of comorbidity (64% and higher) with BH concerns.
The Need for Improvement in Communications Among Professionals Involved in the BH Fields
The average age for disability benefits as called in the SSA's Social Security Disability Insurance (SSDI) program is 52. Because a significant number of chronic physical concerns have also been shown to have a co-occurring BH concern, it becomes apparent the potential impact of BH concerns within the largest public disability program in the United States (SSA, 2008).
Prevalence of Behavioral Health Concerns
One of the primary psychological disorders that occur Major Depressive Disorder has been found to have a prevalence rate of 10-20% in the clinical population of those diagnosed with a psychological disorder (American Psychiatric Association, 2000; Kessler et al., 1996). The Substance Abuse and Mental Health Services Administration (SAMHSA a, 2007b) placed the prevalence rate of a behavioral health disorder much higher, with 30% of the population experiencing a BH dis.
Prevalence of Behavioral Health Concerns and Systemic Issues in Disability Treatment
BH Professionals Involved in the BH Disability Process and Problematic Issues
- Problematic Inconsistencies in Professional BH Training
- Clinical Psychologists
- Physicians
- Lack of Objective Assessment in the BH Evaluation Process
- Problematic Selection of BH Treatment
- Problematic Utilization of Inappropriate or Nonevidence-Based Treatment
It also becomes clear that there are substantial differences in the breadth of professional training that can lead to specific clinical competition. As a result, non-clinicians involved in the BH disability process came to ask the BH TP questions about treatment.
Common Misperceptions That Occur with by All Professionals Involved in the BH Disability Process
- Determination of Functional Impairment Versus Disability
- A BH Diagnosis Is Automatically Equal to Impairment in Functioning
- Behavioral Health Impairment in Functioning Is Permanent
- Inappropriate Usage of Subjective Information Versus Objective Data for Behavioral Health Concerns
- Over-Reliance on Subjective Information in the Diagnostic Process
- Physical Disability Concerns Represent the Majority of the Disability Claims
- Disability Concerns Can Only Be Physical or Behavioral in Nature, But Not Both
- BH Issues Must Be Treated Differently from Physical Issues
- Treating Professionals Are the Most Appropriate to Evaluate BH Impairment in Functioning Issues
- BH Concerns Can Only Be Work- or Nonoccupationally Related
Unfortunately, however, there is no analogous standard in current BH treatment practice (Warren, 2009). Thus, this type of approach can result in the unintended continuation of the individual's suffering.
Causality and Behavioral Health Concerns
- Professional Barriers to Objective BH Causality Determination
The ultimate goal of the BH treatment process is to restore the person to their previous level of functioning (Warren, 2009). Additionally, the AMA Guidelines for the Evaluation of Permanent Impairment (AMA, 2008) require this as part of the BH evaluation.
Causes of Iatrogenic Behavioral Health Disability
- Personal Factors That May Contribute to Behavioral Health Disability
- Treating Professional Causes of Iatrogenic Disability
- Employer Contributory Factors to Iatrogenic Behavioral Health Disability
- Attorney Contributory Factors to Iatrogenic Behavioral Health Disability
- Insurer Contributory Factors to Behavioral Health Disability
A systematic lack of standardization in the types of objective data required to make a decision about a BH disability claim. Additionally, many insurers do not require the use of DSMIVTR diagnoses and standardized objective psychological testing in the claim adjudication process.
Conclusion
Cross-national associations between gender and mental disorders in the World Health Organization World Mental Health Surveys. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (DHHS Publication No. SMA 013542).
The Importance of Appropriate Psychological Evaluation of Behavioral Health Concerns
Current BH Evaluation Model
Effective Psychological Evaluation and
Management of Behavioral Health Concerns
Relationship Status
This section is intended to gather information about whether the person is single or in a relationship. Additionally, if the person is currently in a relationship, careful examination of the quality of the relationship is also done.
Employment Status
It is also important to ask about the person's current living conditions to determine if there are other people, including children, living with the person seeking treatment. This allows the BH assessor to determine if there are any problematic issues related to personal relationships.
Presenting Problem(s)
Inquiries about the number of long-term relationships, including previous marriages, are made to determine whether there are chronic problems within personal relationships. This is important because it establishes a potential pattern of problems within personal relationships that may reflect similar concerns with workplace communication.
Personal Habits
This does not mean that additional concerns cannot be added later, but rather what the individual considers problematic at first. This process also allows the BH assessor to briefly assess the individual's insight, logic and reasoning skills, and to highlight any deficiencies in recognizing serious, unidentified problems.
Social History
If frequent movements are observed, then the BH evaluator should spend time gathering information about the catalysts that triggered the movements. Finally, the BH assessor should ask about religious orientation and spiritual beliefs, and discern whether there are cultural differences that may account for some of the perceived concerns or problematic interactions.
Educational History
Past and Current Psychological History
Medical History
Mental Status Evaluation
Thought processes, thought content and perception: (a) Thought process is directly related to the spontaneous communication process in the evaluation process; (b) thought content relates to specific types of spontaneous speech that may reveal deceptions. Rumination, suicidal and homicidal ideation, as well as phobias to name a few concerns, and (c) perception relates to whether the individual experiences hallucinations, depersonalization, de-realization and the like.
Diagnostic Impressions
As a result, the GAF assessment is of relatively low value in the process of determining a person's level of functioning. This is puzzling, as the GAF score should reflect the individual's basic ability to function in life across a range of settings.
Summation and Treatment Recommendations
The ultimate goal of the BH treatment process is to restore the person to their previous level of functioning. This last aspect is of particular importance, because if the TP treats the person to return to a previous level of functioning, then it may reduce the monetary award or benefits paid to the individual or by a legal proceeding, the compensation of workers. or disability claim systems (Kahn & . Langlieb, 2005; Melhorn & Ackerman, 2008; Warren, 2009).
Additional Assessment Components to Add to the BH Evaluation
- Military History
- Legal History
- Disability History
- Evaluation for Potential Medicalized Issues, Malingering, and Symptom Exaggeration
- Collaborative Communication and BH Referrals
- Corroborating Documentation and Data
- Objective, Standardized Psychological Testing
- Appropriate Documentation Regarding Potential Limitations in Objective Impairment in Functioning
- Drawing on the Strength of Scientifically Based Treatments of BH Concerns
- Appropriate Treatment Goals (Including RTW)
The BH professional should note whether workplace documentation is to be received and what types of information are provided. This allows the bra assessor to understand the biological component of the potential problems.
The Behavioral Health Return-to-Work Process
- Workplace Accommodations for Behavioral Health Concerns
It is important to note that similar science-based treatments exist for many other mental disorders. However, it is still important to be aware that simply asking for accommodation does not necessarily ensure that the employer will provide accommodation.
Conclusion
Langlieb (Eds.), Mental health and productivity in the workplace: A handbook for organizations and clinicians (pp. 347-368). Levant (Eds.), Evidence-based practice in mental health: Debate and dialogue on fundamental issues (pp. 13-55).
Introduction
- Biopsychosocial Aspects of Disability
Assessment of Psychosocial Contributions to Disability
- Subjective Risk Factors for Disability
- The Assessment of Psychological States Leading to Disability
- Psychometric Assessment and Disability
- An Introduction to Psychological Testing Concepts
- What Is a Standardized Test?
- Validity Assessment
- Malingering, Exaggeration, and Denial
- Psychosocial Predictors of Poor Treatment Outcome and Disability
- When to Administer Psychological Tests
- Test Selection
- Conclusions
Not surprisingly, chronic pain has been found to be one of the most costly conditions in managed care (Disorbio et al., 2006). This phenomenon may help explain the wide variation in prevalence estimates of misuse (Bianchini et al., 2006).
Appendix: Psychometric Assessment Tools
Epidemiology and Prevalence of Psychological and Behavioral Health Concerns in Psychiatry
Some psychiatrists have received additional training in more specialized areas such as psychoanalysis, alcohol and substance abuse, geriatrics, neuropsychiatry, or forensic psychiatry. In real-world practice, many individuals with treatable mental disorders do not necessarily receive specific psychiatric or other mental health assessment and care.
Psychiatric Issues in Behavioral Health Disability
Psychiatry and Behavioral Health Disability
Major Depressive Disorder can significantly increase readmission rates and mortality in cardiac patients (Allison et al., 1995). Major Depressive Disorder (MDD) is one of the top five problems associated with absenteeism and presenteeism (an ill employee working at less than full capacity) (Kessler et al., 2001; Rossi, 2001).
The Usual Treatment Process and the Role of the Psychiatrist
- The Traditional Treatment Approach and the Paradigm Shift
- The Usual Treatment Process
- Avoiding Dual Roles
- The Treating Psychiatrist as “Advocate”
- Defining “Disability”
- Challenges for the Treating Psychiatrist
It is important that the psychiatrist has a clear understanding of his/her intended role. The purpose and goals of the treating psychiatrist are fundamentally different from those of the psychiatrist in a forensic role.
Determining Current Psychiatric Functioning .1 The General Psychiatric Evaluation
- The Psychiatric General Functional Assessment
- The Psychiatric Occupational Functional Assessment
It is essential that the psychiatrist differentiates between the patient's symptoms (the patient's self-report) and the psychiatrist's findings and observations. The starting point for this assessment is the psychiatrist's findings and observations, as opposed to the patient's self-reported symptoms, as described above.
The Psychiatric Referral and the Occupational Referral .1 The General Psychiatric Referral Process
- The Occupational/Workplace Psychiatric Referral
- The Occupational Psychiatric Referral in Practice
For the psychiatrist, the occupational function assessment forms the basis for incorporating a return plan into the overall treatment plan for the patient. If the psychiatrist makes an appropriate occupational assessment based on findings and observations and corresponding impairments – and does not base the occupational assessment exclusively or primarily on self-reporting of symptoms or on diagnosis – there may well be a difference in what the patient says. he or she can and cannot, and what the psychiatrist believes the patient can or cannot do.
Medicalization
- The Process of Medicalization and Psychiatric Context
- Overmedicalization in the Mental Health Disability Process
In the process of psychiatric disability, there is a tendency for patients and many psychiatrists to "over-medicalize"—specifically, to medicalize "stress" or issues such as job dissatisfaction, workplace conflict, marital problems, and non-work-related family care. or other requirements. The former is more likely to seek "disability transition" as a way of dealing with "stress". It is very important that the psychiatrist does not treat this as a mental health disorder.
Symptom Exaggeration and Malingering .1 Malingering and the Disability Process
- Malingering and Psychiatric Disorders
- Psychiatric Response to Suspected Malingering
The psychiatrist may take into account some other somatoform disorders, defined in DSM-IV-TR, in the differential diagnosis. The psychiatrist may attribute suspected malingering to poor motivation or effort, and/or medicalize this as part of the claimant's illness.
Patient Compliance Issues
- Compliance and the Psychiatric Patient
- Identifying Noncompliance
- Treatment Approaches to Improve Compliance and Prevent/Reduce Noncompliance
In maintaining the therapeutic alliance, the psychiatrist must be aware that the patient's personal beliefs have a major impact on his or her compliance behavior. It is vital that the psychiatrist seeks to understand the patient's perspective – what the patient believes about the prescribed medication.
Appropriate Documentation of Impairments and Limitations in Functioning
In addition, maintaining targeted documentation allows the psychiatrist to communicate clearly with others involved in the patient's treatment. It is in the patient's interest that the treating psychiatrist documents this clearly and accurately.
Treatment Outcomes: Strategies for Addressing Return to Work
To this end, the American College of Occupational and Environmental Medicine adopted a guideline in 2006, based on the work of the college's Stay-at-Work and Return-to-Work Process Improvement Committee (ACOEM, 2006). Assessment and treatment of psychiatric work-related disability: new behavioral health functional assessment tools facilitate return to work.
Epidemiological and Prevalence of Psychosocial and Behavioral Health Concerns
The Occupational Medicine Perspective on Behavioral Health Concerns
Discussion of Usual Care Treatment Process: Strengths and Weakness Within Occupational Medicine
Most occupational medicine private practice physicians trained for residency in another field and developed an occupational medicine practice over time after their formal medical education was completed. Additionally, occupational medicine physicians can allocate more time per patient visit compared to surgeons, as their hourly labor costs are less.
Determining Current Psychiatric Functioning: Strengths and Weakness Within Occupational Medicine
Thus, the current system encourages the patient to conceal, consciously or unconsciously, the existence of psychosocial factors in order for the injury or illness to be accepted as compensable; the current system encourages the doctor to spend less time with the patient than with patients with other funding sources; and the insurer has financial incentives to refer patients to physicians who ignore psychosocial issues. Another assessment method is for the physician's office staff to have patients complete pain charts or questionnaires that screen for psychosocial issues.
Referral and Coordination of Treatment Considerations
Are you worried that something bad is causing your pain but hasn't been found. What do you like about your job and what do you dislike about your job.
Strengths and Weaknesses in Current Processes
- Medicalization
- Symptom Exaggeration and Malingering
- Patient Compliance Issues
- Appropriate Documentation of Limitations in Objective Impairment/Functioning
- Treatment Outcome: Strategies for Addressing the Individual’s Return to Work
- Epidemiological and Prevalence of Psychological and Behavioral Health Concerns in PT
Conversely, if marital distress is labeled by a physician as "degenerative disc disease," the patient becomes convinced that a medical illness is present that requires medical treatment. The workplace may present psychosocial issues that hinder patients' return to work and symptom reduction.
Physical Therapy Treatment and the Impact of Behavioral Health Concerns
Discussion of Usual Care Treatment Process
Physiotherapy treatment is started, the patient's response to the treatment is monitored and the program is progressed. The PT does not have the expertise to either diagnose or treat the patient's problem.
Determining Current Psychiatric Functioning and/or Behavioral Health Concerns, such as Fear
- Referral and Coordination of Treatment
- Medicalization
- Symptom Exaggeration and Malingering
- Patient Compliance Issues: Limitations and Strategies for Improved Management
- Appropriate Documentation of Limitations in Objective Impairment/Functioning
- Treatment Outcomes
- Summary
- Introduction
A medical case manager involved with the patient can be a useful source of information for the therapist. It is important that the therapist listens to the patient's concerns and feelings and treats them with respect.
Vocational Rehabilitation Considerations for Mental Health Impairments
One professional discipline that addresses employment issues for persons with disabilities is vocational rehabilitation. Vocational rehabilitation is offered in a variety of settings, including but not limited to workers' compensation (WC), short-term disability (STD), and long-term disability (LTD) benefits.
Prevalence of Psychological and Behavioral Health Concerns in Vocational Rehabilitation
Employment rates for people reporting severe mental illness were even lower, ranging from 32 to 61%. People with any mental illness are employed at lower rates than people without mental illness; the rates for people with serious mental illness are even lower.
The Mental Health Conundrum: Impairment Versus Disability
The Diagnostic Statistical Manual of Mental Disorders (DSM-IV 4th edition, text revision) indicates, "when the existence of a 'mental disorder', 'mental retardation', 'mental illness' or 'mental deficiency' is established, additional information about an individual's functional impairments and how these impairments affect their abilities usually goes beyond what is required in the DSM IV. does not imply a specific level of impairment or disability... The problem raised by the term mental disorder was far more obvious than its solution, and unfortunately the term remains in the title of DSM-IV because we do not have a found a suitable replacement.
Vocational Rehabilitation: The Treatment Process
- Assessment and Appraisal
- Career (Vocational) Counseling
- Vocational Rehabilitation Plan of Service
The plan is signed by the individual in need of services and often by the vocational rehabilitation supervisor. If you don't do this, it can weaken the individual's trust in the plan and the vocational rehabilitation supervisor.
Other Considerations in Vocational Rehabilitation .1 Malingering and Compliance with Services
- Job Descriptions
- How Are Essential Functions Determined?
Falvo, "An individual's ability to function in a job may depend on cognitive, psychomotor, and attitudinal factors as well as on the physical aspects of illness or disability. Since vocational rehabilitation focuses on the employment of individuals with disabilities, rehabilitation counselors rely heavily on job descriptions for to identify job requirements and then link it to the individual's impairments.
The Dictionary of Occupational Titles
- Temperaments
- Procedure for Rating Temperaments
This book provided detailed descriptive information on how to measure each of the employee characteristics in the DOT. The USDOL no longer supports the DOT and advises users to exercise caution due to the age of the DOT data.
The O*NET
The work requires maturity, poise, flexibility and self-control to deal with pressure, stress, criticism, setbacks, personal and work-related problems, etc. At the end of this chapter you will find a sample job description that includes many of the job requirements that are discussed here. .
The Vocational Rehabilitation Tool Box
- Case Management
- Situational Assessment/Work Adjustment
- Adjustment Counseling
- Transferable Skills Analysis
- Return to Work Services
- Transitional Work Programs
A Situational Assessment or Work Adjustment Program involves the placement of the incumbent in a work simulation outside of one's regular place of employment. Transitional work policies are often developed by a vocational rehabilitation counselor with assistance from the employer.
Summary
Transitional work programs must be time-limited, with the expectation that the incumbent will be placed in regular employment upon completion of the program or placed on leave status. Transitional work programs can help alleviate the treating medical professionals' fear of agreeing to an early release to work while treatment continues.
