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by Gregory T Hale, Ph.D.
The role and
purpose of psychological evaluations in understanding behavioral
problems is more clearly understood and accepted for providing
clarification in medical and psychological disorders. In the case of
a worker’s compensation claim, any type of complicated medical and
psychological disorder is affected by how the diversity of human
behavior affects the reactions of the injured worker. The disparity
and recovery time required following a work related injury populations
it even more difficult to predict who is going to respond positively
to the medical and psychological interventions employed to aid
recovery. The psychological and medical literature documents the
variable recovery rates for Worker's Compensation patients compared
with those from a noncompensation population. In addition,
psychological evaluations for those being considered for implantable
devices and surgical intervention indicate psychological and
behavioral factors are critical to the decision making process and
success rate of such procedures.
Various types of
stressors contribute to the difficulties often experienced by
med/psych patients. The associated problems of physical illness,
injury, increased somatic symptoms and sleep disturbance contribute to
increased psychological stress and interference with occupational
capability and the basic ability to manage the environmental changes.
This causes an increased number of risk factors that contribute to the
behavioral and psychological response of medical patients and
influence their recovery. It may even interfere with their ability to
overcome some of the difficulties being experienced. Multiple
surgical procedures, repeated experiences in physical therapy and
rehabilitation provide both a source of comfort and add to the stress
experienced by many medical patients. How a person responds to these
various stressors in the course of their treatment can significantly
impact their recovery. For this reason, understanding who was injured
is often as important as understanding the injury.
There seems to be
great variability, however, in how psychological information is
gathered. Clarifying the behavioral aspects of the med/psych case and
determining which medical and behavioral interventions are likely to
be successful is critical to designing the behaviorally meaningful
psychological examination. More importantly, who conducts the
examination based on their expertise and understanding Worker's Compensation claimants is also critical. Unfortunately, mental health
professionals receive limited training in legal issues, and no
training in understanding worker’s compensation. In addition,
external motivating factors in a Worker's Compensation case often
negatively impacts the recovery process. Thus, the assessment of
dissimulation or response bias is needed. Once again, mental health
professionals are rarely trained to assess dissimulation or to
question the role of secondary gain.
What is the role of
a psychological evaluation in a Worker's Compensation claim? First, to
establish what psychological factors and psychological disorders, if
any, impact the patient’s behavior. This is determined by conducting a
psychological examination and identifying psychological disorders with
the assistance of the DSM-IV-TR. Secondly, are the medical
professionals confronting and trying to manage subjective or objective
symptoms? That is, do psychological and behavioral factors impact
symptom perception as well as the behavioral presentation of the
patient? A final aspect of the psychological examination is to
determine if the legally relevant event caused the psychological
disorder. In addition, some events aggravate underlying psychological
disorders. Thus, psychological evaluations help to clarify those
disorders which are pre-existing and existed co-morbidly with the
psychological disorder which is causally related to the work event.
The structure of the
psychological evaluation is based on conducting a complete diagnostic
interview. The diagnostic interview is an integral aspect of getting to
understand the alleged psychological and physical complaints. The
results of the psychological evaluation should not be based solely on
self-report. That is, the determination of causation and other issues
critical and appropriate to understanding a Worker's Compensation claim should not be based simply on a diagnostic interview
or limited to the self-report of the claimant. Psychological testing
should be administered which is designed to assess the current
complaints. These tests should be normatively based psychometric
measures that provide clarification of the complaints and behaviors
reported. Reviewing medical and psychological records pertinent to the
claim aids in understanding the behavioral patterns of the claimant.
Being able to compare data from multiple sources aids in determining the
consistency of the symptoms and helping to clarify the credibility of
the symptom report. Without such information it is nearly impossible to
determine a cause and effect relationship. Moreover, concurrent
psychological stressors can be identified. Most importantly, comparing
the consistency and inconsistency of the data is achieved.
By utilizing
multiple data sources clinical judgment is then based on multiple
sources of information and not simply on clinical judgment. Clinical
judgments are often lacking in accuracy when clinicians base their
opinions simply on clinical experience or the self-report of the
patient. These clinicians are prone to making significant errors in
judgment and overlooking meaningful pieces of clinical information.
Thus, an appropriate psychological examination encompasses an interview,
psychological testing, record review, mental status observation, and
comparison of data from multiple sources before determining an outcome.
The
ultimate value to claims examiners and physicians in requesting a
psychological examination is that it helps those who are involved in
treating the patient to better understand the effects of the
work-related event and psychological disorder. The life of the
claimant, prognosis for recovery, and treatment needs can also be
facilitated. This helps to determine what is necessary to regain useful
function, thus reducing the possibility of permanent impairment. In the
medical context, the information gained from a psychological evaluation
helps physicians sort out additional information that will enhance their
ability to determine which patients have a better and more reasonable
prognosis for benefiting from the medical treatment recommended and
provided. The key is to make the information relevant and useful to the
recovery of the injured worker.
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