Those Who Hesitate are Lost: The Case for Setting Behavioral Health Treatment and Disability Standards, Part II

In the first article of this three-part series, an overview of systematic problems related to behavioral health (BH) treatment and disability was discussed. In this second article of the series, I discuss a number of factors that contribute to the lack of standardization regarding the work of all professionals in the area, including those in the BH field, which serve to introduce imprecision into the BH treatment and disability determination processes. From how professionals are trained and continuing to those who are providing clinical treatment, it is essential to understand how the lack of standardization impacts the treatment itself as well as treatment outcomes. This lack of standardization contributes to poorly identified mental health (MH) conditions, no identification of psychosocial issues, and an overreliance on subjective information, including professional clinical opinion, which leads to poorly defensible professional decision-making as well as poorer outcomes in treatment. In this litigious age, it is not sufficient to employ clinical opinion alone as the basis for treatment decisions. The more sophisticated professional recognizes the importance that one's assessment and treatment decisions may later be questioned in court or in a disability determination hearing. The importance of standardization and utilizing the current scientific standards has become imperative in today's professional evaluation and treatment in the area.     

Those Who Hesitate Are Lost: The Case for Setting Behavioral Health Treatment and Disability Standards, Part I

There are multiple factors that impede the implementation of standards into the behavioral health (BH) treatment and disability processes. The combination of physical and psychological conditions as well as the influence of psychosocial issues has consistently been identified as having negative effects on treatment and treatment outcomes. Further, the wide-spread lack of standardization causes a multitude of problems throughout both BH processes. The focus of this first article in a three-part series will examine the explosion of behavioral health claims and the major factors, such as comorbid physical conditions and psychosocial issues, associated with these types of claims. In addition, the overarching theme of lack of standardization will begin to be explored in regard to the problematic definition of disability, communication difficulties between treating professionals and disability insurers and agencies as well as the introduction of bias into the BH treatment and disability processes.     

我国视损伤残疾评定标准问题研究

视损伤评价是制定视损伤残疾标准、统一标准适用的基础。由于基本问题缺乏界定与研究,导致我国残疾标准制定困难、理解适用混乱,影响了鉴定意见的科学性。应解决视功能含义、确定视残疾与个体残疾的关系、拣选检验指标、开展视残疾生存质量调查和一体评价视损伤等主要问题,加强残疾理论与法学、临床医学等其他学科的交叉研究,建立适合我国社会发展需求的残疾评价体系,促进残疾评定的科学化和标准化。     

Workers’ Compensation Claimants with Low Back Pain: the Role of Dissatisfaction in the Transition to Disability

Workers’ compensation systems represent naturalistic settings that often are perceived as unjust by the injured workers for which such systems were developed. This study examined the role of dissatisfaction with medical care and employer treatment on disability outcomes among a cohort of workers who had sustained low back injuries. A race-stratified sample of 358 workers (171 African-Americans, 203 Caucasians) with first incident low back pain was evaluated 21 months and again at 72 months after claim settlement. Evaluation included data related to demographics, socioeconomic factors, injury severity, claim settlement, satisfaction with workers’ compensation (WC) processes, and disability status. Multinomial logistic regression analysis was used to predict disability status (no disability vs. early disability vs. late disability) at each of the two time points. Analyses revealed contributions of multiple variables to early disability, including unique variance related to dissatisfaction with medical care and treatment by the employer. At 72 months, only demographic factors (age, race) and the receipt of temporary total disability (TTD) after injury predicted late disability. Results are discussed relative to the contribution of injustice perceptions and systemic factors; directions for future research are proposed.     

交通伤后遗智力缺损或精神障碍伤残评定资质问题探讨

近年来,交通伤后遗智力缺损或精神障碍伤残评定日益增多,实际评残操作不规范,造成鉴定意见不一致经常发生,影响鉴定质量和交通事故处理。当前,部分鉴定机构及其鉴定人的资质问题已经受到交通事故处理机关的质疑,也引起司法鉴定管理部门的关注。对此,就精神伤残评定资质问题从程序规定角度和技术操作层面展开讨论,力图为精神伤残评定的规范操作提供一些思路。     

Strategic Standardization in Europe: A Public Choice Perspective

In October 1990, the EC Commission presented a Green Paper in which it outlined a New Approach to European standardization. In particular, standardization was interpreted as a means of furthering the completion of the Internal Market. This paper discusses the impact of the modifications to the process of standard setting, as they have been proposed by the Commission, with respect to the incentives and goals of the major players in the European standardization game, i.e., national and European standardization bodies, industry and the EC Commission. Selected economic models of standardization are applied to investigate the policy impact of the New Approach.     

关于《道路交通事故受伤人员伤残评定》中若干技术难题的处理办法(下)

由于《道路交通事故受伤人员伤残评定》中许多条文的规定比较笼统和原则,在理解和掌握上尚有一定的困难。为此,作者参考国家有关鉴定标准和临床医学有关器官功能障碍分级方法,并结合作者在伤残评定中所积累的经验,提出有关评定标准的细则,旨在推动鉴定工作的统一和规范,确保鉴定结论的公正和科学。     

关于《道路交通事故受伤人员伤残评定》中若干技术难题的处理办法(上)

由于《道路交通事故受伤人员伤残评定》中许多条文的规定比较笼统和原则,在理解和掌握上尚有一定的困难。为此,作者参考国家有关鉴定标准和临床医学有关器官功能障碍分级方法,并结合作者在伤残评定中所积累的经验,提出有关评定标准的细则,旨在推动鉴定工作的统一和规范,确保鉴定结论的公正和科学。     

Biopsychosocial Considerations in Unnecessary Work Disability

The current definition and management of medical conditions causing impairment and unnecessary disability in workers’ compensation (WC) systems are suboptimal. Fundamental problems include the failure to recognize and address the unique biopsychosocial diathesis of each individual; the powerful influence of human psychology in the genesis, perpetuation, and refractoriness to treatment of many conditions, including medically unexplained symptoms and chronic pain; the work relevance of even non-work-related conditions; the considerable effects of administrative and clinical iatrogenicity; and the plethora of complex factors potentially affecting the course of conditions treated in WC systems. Once claims are established in WC, administrative and medical management of both identifiable pathologic conditions and unexplained symptoms are fragmented, not based on available scientific evidence, and adherent to a biomedical care approach which is not appropriate for a significant number of cases. These obstacles prevent effective understanding and management of many WC cases and may contribute to eventual recovery failure and unnecessary work disability (UWD). This article explores biopsychosocial factors in WC claimants and elements that may contribute to or ameliorate progression to UWD. The author offers a heuristic diathesis stress model of work-related disability as a framework for general and specific interventions to improve system performance and outcomes for all stakeholders.     

Psychological Injury and Law: Introduction to the First Issue

In this introductory article to the special series of articles written to initiate the new journal, Psychological Injury and Law, I provide the background and impetus for this fast-growing area as a distinct field of scientific study. Professionals working in the area need to be aware of its diverse components, from evidence law and forensic psychology to disability and assessment, to its three core areas of Posttraumatic Stress Disorder and other distress, chronic pain, and traumatic brain injury, as well as issues such as malingering. I provide summaries of the articles in this special series that appear in this inaugural issue. The remaining articles of the special series of articles to introduce the journal are presented in the next two issues.     

Work Impairment and Disability in Posttraumatic Stress Disorder: A Review and Recommendations for Psychological Injury Research and Practice

Work impairment and disability are common consequences of posttraumatic stress disorder (PTSD), as reflected by significant rates of sickness absence, failure to return to work, and reduced work performance. Within the psychological injury field, the issue of work impairment and disability in PTSD often arises in workers’ compensation and disability insurance claims and in personal injury litigation. In this context, clinical and forensic practitioners are faced with challenges in rendering expert opinions on diagnosis, causality, prognosis, and recommendations for treatment and rehabilitation. To promote understanding of this important, yet understudied area, there are three aims of this paper: first, to review the current literature on work impairment and disability associated with PTSD; second, to draw on this literature to present a biopsychosocial framework of work impairment and disability in PTSD; and third, to offer suggestions for improving the assessment and management of PTSD-related work impairment and disability.     

Re‐Claiming Disability: Identity,Procedural Justice,and the Disability Determination Process

This research highlights the crucial role of an intimate link between a disabled person's self‐identity and the perceived fairness of legal procedures. In doing so, it brings to the foreground a wholly ignored aspect of procedural justice. Earlier researchers have failed to delve into the role identity politics plays in the relationship between the institutions and the beneficiaries of their services, and the way different members of a group understand and define themselves. This research explores the way people with disabilities in the United States, with different kinds of disability identities, experience and evaluate the procedure of claiming Social Security benefits. The findings suggest that disabled people who identified with the social model of disability (as opposed to the medical‐individual models) hold a critical view of the procedure for retaining benefits. They felt they had no control over it, could not voice their opinions, were mistreated by representatives, and had to present an image that was not necessarily true of their disability. They also saw the procedure as discouraging them from participating fully in the labor market, and consequently integrating better in society, an idea that was not present among disabled people who identify with medical‐individual models. Exposing this relationship between the way people perceive themselves and the way they experience and evaluate legal procedures can contribute to the creation of better policies, while improving communication between the state and members of the disability community, along with other marginalized groups.     

Work and mental health: learning from return-to-work rehabilitation programs designed for workers with musculoskeletal disorders

Despite the high costs associated with mental health problems in the workplace, few studies have yet been published on the design and evaluation of return-to-work rehabilitation programs for workers with mental health problems. In fact, the best-documented return-to-work rehabilitation programs concern workers with musculoskeletal disorders (MSKD). For this clientele, a disability paradigm has been adopted which explains the multicausality of work disability. Long-term work disability is no longer seen simply as the consequence of impairment, but rather as the result of interactions between the worker and three main systems: the health care, work environment and financial compensation systems. A return to work is thus influenced by a complex set of interrelated factors that must be taken into account in any intervention. Parallels can inevitably be drawn in the field of mental health in the workplace, where individual and organizational factors are involved and must be taken into account in the return-to-work process. This paper presents the first results of an exploratory study aimed at determining the possible links between work rehabilitation programs for workers with MSKD and those for workers with mental health problems. To this end, the components of a work rehabilitation program for workers with MSKD, the Therapeutic Return to Work (TRW) program which addresses psychological factors, work environmental factors and factors related to the involvement of the various stakeholders in the rehabilitation process, are described through a multiple-case analysis and mapping of interventions. The results support the relevance of adopting the disability paradigm and considering the return-to-work clinical activities conducted with workers with MSKD (and their mechanisms of action) in the design of work rehabilitation programs for workers with mental health problems.     

The Usage of the AMA <Emphasis Type="Italic">Guides</Emphasis> for the Determination of Psychological Injury Within the State and Federal Workers’ Compensation Systems

Psychological injuries, like physical injuries, may occur within the workplace. If those injuries are reported to be a result of a triggering event in the workplace, then a workers’ compensation (WC) claim may be filed by the individual. State WC and the federal WC systems have laws and rules in place to address workplace psychological injury claims. However, because each State has its own WC State laws as does the federal WC system, there is no current standardization in defining either psychological injury or in defining disability. This is because each system has its own definitions. A few States allow workplace psychological injury claims. Some States do not accept WC psychological injury claims. The remaining States recognize workplace psychological injuries but with specific limitations. The federal WC system allows WC psychological injury claims. There are problematic issues that occur in the State and federal WC systems. These issues are utilizing outdated terminology, employing outdated diagnostic criteria, and allowing documentation submission and professional opinion that does not comport with current professional standards of care. In addition, the need for a definitive answer to address causation is not always possible to address with regard to psychological injury. These types of issues introduce imprecision into the determination of psychological injuries. To address these concerns, the American Medical Association developed the Guides to the Evaluation of Permanent Impairment as a means to take a more scientific approach to the assessment of impairment. This stance was a move away from the poorly defined term, “disability”. The focus was on evaluating the individual’s functioning in terms of impairment. The AMA holds that this is a more objective method that provides a balance between clinical opinion and the utilization of a more scientific methodology that increased precision in the determination of psychological injury and purported impairment in functioning that may have resulted from the injury. The American Medical Association’s Guides to the Evaluation of Permanent Impairment are utilized by many States and the federal WC systems to assist in the evaluation of psychological impairment in functioning and in the WC claims process. Some States opt to use earlier editions of the Guides. Other States and the federal WC system require the usage of the most current edition of the Guides. A few States opt to forego the usage of the Guides altogether and develop State-specific guidelines. The complexities that arise within the WC systems as well as usage of the Guides to evaluate and assess psychological injury are explored as well as potential solutions to address the imprecision that occurs within the WC systems.     

Revised medical criteria for evaluating impairments that affect multiple body systems. Final rules

We are revising the criteria in the Listing of Impairments (the listings) that we use to evaluate claims involving impairments that affect multiple body systems. We apply these criteria when you claim benefits based on disability under title II and title XVI of the Social Security Act (the Act). The revisions reflect current medical knowledge, methods of evaluating impairments that affect multiple body systems, treatment, and our adjudicative experience.     

Intervention with sexually abusive young people in Australia and New Zealand

Abstract

Research into the treatment of sexual offenders with an intellectual disability has increased over the past decade. This research can be used to investigate the efficacy of treatment; however, empirical limitations of the research make generalizations difficult. Marques has provided a framework for examining treatment efficacy that emphasizes the contribution of researchers and clinicians to report treatment outcomes rather than a strict reliance on rigorous empirical investigations, such as controlled outcome research. This review uses Marques’ framework to present an overview about group treatment for sexual offenders with an intellectual disability using nine identified studies. This paper attempts to consolidate our knowledge about specific treatment issues, while demonstrating the varied outcomes that are reported in the literature. In employing this framework, the literature suggests that our knowledge can be substantially improved by research addressing specific areas of treatment.     

Extension of the expiration date for several body system listings. Final rule

We use the Listing of Impairments (the listings) at the third step of the sequential evaluation process when we evaluate your claim for benefits based on disability under title II and title XVI of the Social Security Act (the Act). This final rule extends until July 3, 2006, the date on which listings for four body systems will no longer be effective and extends until July 2, 2007, the date on which the listings for eight body systems will no longer be effective. Other than extending the date during which the listings will be effective, we have made no revisions to the listings; they remain the same as they now appear in the Code of Federal Regulations. This extension will ensure that we continue to have the medical evaluation criteria in the listings to adjudicate disability claims in these body systems at step three of the sequential evaluation process.     

Disentangling the Disability Quagmire in Psychological Injury and Law

This paper aims to critically analyze the evolution of six models of conceptualization, determination, and prediction of occupational disability relevant in the medico-legal context of psychological injury. The six models are the (a) biomedical, (b) forensic, (c) psychosocial, (d) ecological, (e) economic, and (f) biopsychosocial. We will discuss the key commonalities and differences among the models, including disciplinary tradition, research paradigm, recognition of person–environment interaction, key tenets, and implications for practice and research in psychological injury. The paper will highlight and discuss psychosocial issues, often underemphasized in forensic psychological practice, including: (a) balanced assessment of primary, secondary, and tertiary gains and losses, (b) self-perception, (c) disability identity, (d) beliefs and expectations, (e) coping, (f) adaptation and positive growth, (g) social stigma and social reactions to disability, including disability harassment, and (h) recognition of system-based environmental influences and demands. We will provide a special focus on the current state of the science and practice of prediction of disability, of particular interest to researchers and clinicians involved in clinical and occupational prognostication in psychological injuries. Finally, we will draw conclusions and recommendations for future research and best practices in the psychological injury area using a cross-diagnostic, dynamic, functionally based, and integrated biopsychosocial and forensic model of disability.     

Schedule for rating disabilities; AL amyloidosis (primary amyloidosis). Final rule

The Department of Veterans Affairs (VA) is amending its Schedule for Rating Disabilities by updating the schedule of ratings for the hemic and lymphatic systems to include AL amyloidosis. This regulatory action is necessary to add AL amyloidosis as one of the disease conditions and establish criteria for disability evaluation to fully implement the decision by the Secretary of Veterans Affairs to grant presumptive service connection based on herbicide exposure for this disease. The intended effects are to provide consistency in disability ratings and to ease tracking of AL amyloidosis for statistical analysis.