““Focus on Functioning”Focus on Functioning”

when making clarification when making clarification callscalls

Todd Finnerty, Psy.D.Todd Finnerty, Psy.D.

•Objective

Objective

ss

Welcome and Good MorningWelcome and Good Morning

• Participants will be able to Participants will be able to apply an approach to making apply an approach to making phone calls which attends to phone calls which attends to the impact allegations and the impact allegations and symptoms have on the symptoms have on the claimant’s functioning.claimant’s functioning.

How are you today?

Describe the practical application of theoretical issues impacting the phone call

Develop and utilize effective techniques for clarification/ADL calls

• Objectives

Objectives

Reach out and touch someone

options for functional information:ADL formsPhone call with cltCollateral Contact with a 3rd partyReports contained in the evidence (school,

work, treating and examining sources, etc.)Adaptive behavior scales (ex: VABS)

Benefits of a call?

Can making clarifying calls improve the quality of your decisions, make them easier to draft (since you have increased access to relevant functional info) and bring in more support for your decision whatever it may be?

Navigating the tides of change…

• DSM5.orDSM5.orgg

Don’t be surprised…(but not final)

Intellectual disability instead of MR Temper Dysregulation Disorder w/ Dysphoria? Aspergers --> “Autistic Spectrum Disorder” Neurocognitive disorders instead of dementia Mixed anxiety and depression (is that 12.04 or

12.06?) Chronic Depressive vs Dysthymic Complex Somatic Symptom Disorder? Revised Axis I and II; dimensional scales Panic Disorder and Agoraphobia dx separated

DSM-5 expected May, 2013

Diagnoses may change, but your clt will still avoid crowds

What does having a MDI alone tell you about how a clt functions?

Blue Book Definitions

“Symptoms are your own description of your physical or mental impairment(s).”

Signs are “medically demonstrable phenomena that indicate specific psychological abnormalities…”

Symptoms do not equal Functioning

If you only have the clt repeat their allegations to you, what have you clarified?

2 people reporting the same symptoms may deal with them differently and they exist in different environments

Don’t ignore how they impact functioning

Why am I here?

Is listing signs and symptoms sufficient for you to accomplish a disability determination?

How do we measure the impact of these signs and symptoms?

Our Case Study

Lets pretend this imaginary clt alleged depression and anxiety. The clt reported currently being enrolled in college. They reported briefly going to the college counseling center (not currently in file and not currently a patient), and having been in the hospital once overnight due to psych concerns. The only MER we have received so far is from when the clt was hospitalized overnight

Our Case Study

When you make a phone call chances are you may have already received some evidence to be reviewed.

Quick Summary of the available case evidence we have received so far to be reviewed prior to our call:

Our Case Study

Pay attention to some of the signs and symptoms noted in the evidence we have received. They may be a source of questions and discussion on your clarification call.

Our Case Study

The MSE noted a report from the roommate about bizarre behavior lately. He had been repeatedly messaging a girl but the attention was unwanted and the girl may have filed a complaint. He may have referred to himself as “Question Mark” and indicated “Seung” (the clt) was his twin brother.

Our Case Study

The NP noted the clt to be “very resistant to discussing how he feels,” very nonverbal, just looks down at the floor. He e-mailed a friend that he was thinking about suicide, states he was “just kidding around” (the friend called police).

No MDI at discharge?

He states “it was all a joke.” He didn’t report any major problems in his college curriculum. His cognitive exam was WNL. He was kept overnight and received no diagnosis at discharge. The MD noted “essentially it does not appear that he had any serious intent when he made the suicidal statement.” GAF 60-65.

Signs and Symptoms?

The clt actually doesn’t appear to report that many symptoms in the MER, he reportedly denied depression, anxiety and suicidal ideation.

The observed signs vary depending on the source noted.

Proceed w/ a no MDI PRTF?

It is true that the clt’s allegations may not be credible given that he is a college student and has denied depression and anxiety in the MER despite depression and anxiety being his allegations...

Do we know how he typically functions in college, etc? (We’ll come back to the case study).

The devil is in the details

If a claimant tells you on the phone that their mental or physical impairment does not prevent them from working we can’t stop the conversation. We need to also ask questions related to specific functional areas and abilities.

Functioning per our Program

Concentration, persistence and paceSocial FunctioningActivities of Daily LivingDecompensations of extended duration

Defined as:

We could try to define “anything” using independence, appropriateness, effectiveness and sustainability.

Can you address these in a phone call?

Frequency, Intensity, Duration

2 people may both allege “panic attacks”A person may describe a panic attack

where they worry for one minute, once per year. Another may describe a 20 minute panic attack with lots of physical symptoms which occurs an average of three times per week.

“Case by Case basis”

How do you know how to ask the “right” questions and what are they?

Lead a discussion centering around the clt’s allegations and these domains while focusing on factors like… independence, appropriateness, effectiveness and sustainability; frequency, intensity, duration.

Other factors to consider…

Consider developmental milestones; are they engaging in “age appropriate” activities?

No Man is an Island

People function as individuals that exist in broader environmental contexts

What accomodations or assistance allows them to function the way they do?

Write this down…

Regardless of what questions you asked, your best phone call was the one you documented well

Write this down…

Did it really happen if it wasn’t written down?

Observe and report

You can document what the clt said, but when applicable you can also record what you “observed” on the phone call (respectfully).

Who are you? What is the point?

Are you an adjudicator or a biographer?

Keep an understanding of what the point of calling the claimant was.

Careful!

You don’t know where that clt has been, or where they’re going.

Can you establish a sense of their direction on the phone call? (prognosis?)

Swami says…

Can we “project the probable duration” of their impairment?

How did they function before and after onset; acute onsets vs gradual decline; chronic and/or recurrent histories of problems; decompensations.

Those who don’t learn from history-

Even if prior to the AOD, things you may learn about on a phone call such as past episodes of depression over the course of the clt’s life and a past history of multiple treatment attempts/ failed treatments may impact their current prognosis.

Our Case Study

College student, no MDI at d/cWould you call this a decompensation of

extended duration? Predict improvement or that it will not last? What might you talk about on the phone to clarify this further?

Do we know what he was like the week before?

For discussion…

What would you do if on the phone a claimant told you they were going to kill themselves?

Put your oxygen mask on first

Practice appropriate self-care If you “burn out” will you care what

questions you asked or what happens to the claimant’s problems?

Finally, the right questions to ask…

The list of all questions is on the next slide…

?

Use the force…

There are lots of ways to paint a picture, and no one set of questions that all have to be asked.

Be Inappropriate.

What can a Psychologist tell you about interviewing people? Sometimes you have to move beyond social pleasantries (in a respectful, sensitive and appropriate manner).

Socially appropriate?

If you ask the claimant “how are you doing?” and they say “fine,” it isn’t an indication of malingering if they tell their doctor they aren’t “fine.”

Building rapport and comfort may help reduce responses with limited detail

Our Case Study

For example, “the hospital said that you said you were just joking and that you denied experiencing anxiety and depression, can you help me understand that?”

Where do we start?

Preparation makes being comfortable and relaxed easier (helps w/ rapport)

Review the evidence in the file so you can ask pertinent questions

Prepare a note summarizing important issues and questions (it may also help you or someone else later).

Get the ball rolling

Basic questions like any new treatment providers, CE willingness, etc. may help break the ice and get the conversation going.

You can then move on to descriptions of their allegations and how they impact daily activities, or other specific issues which need to be clarified.

Reflective Listening

Make statements summarizing back main points that the person has made without including significant judgments on your part

Reflective Listening

Helps to build rapportHelps to test whether you are

understanding the person and actively listening

Offers the clt an opportunity to elaborate on statements they have made (without even asking a real question).

Reflective Listening

Ex: [Claimant] “I can’t seem to get up the nerve to be around anyone anymore, I get all hot and tense.”

[Adjudicator] “so it sounds like you’re anxious around other people.”

[Claimant] “yeah, I can’t even go in to the store anymore, I’ve driven there before and just sit in the parking lot. My sister shops for me now.”

Follow up questions

You don’t have to move on to a different topic until you’re ready to.

Can you tell me more about that or give me an example of a time when it was a problem?

Can you help me understand what that is like for you?

How do you word your ?

Open-ended questions may be more useful than questions with yes/no responses

Ex: How do you spend a typical day? vs do you brush your teeth?

Some reasons for making a call

To obtain general ADLsWorsening alleged on reconA potential “rule out”3rd party perspectivePossible inconsistenciesSubstance use

General ADLs

Could make a phone callDo you have sxs reported with no clear

indication of how they impact fx?How about t/s opinions with limited

actual mental status or other observations?

Whats new?

If the clt alleges worsening on recon it is a good idea to clarify how their functioning has changed.

The potential rule out

Focus on functioning and don’t simply seek a “reserved for the commissioner” opinion from the clt about their own potential impairment.

While it may not “prevent them from working,” it may create limitations.

Beware of embarrassment and socially appropriate responding

Don’t try to make your clt drink…

…or lead them to water.In fact, don’t try to feed them at all.Ex: rep websites/blogs

3rd party collateral contacts

General considerations:Should not be undertaken without

permissionWhat is their relationship? nature of their

contact?

Inconsistencies

There will always be inconsistencies (sometimes)

All inconsistencies are not created equal, and one inconsistency does not equal malingering.

When in doubt, follow up with a clarifying call

3rd party and inconsistencies

3rd party’s offer “another perspective.” however no two people should ever be expected to see things exactly the same way.

3rd party’s also do not have access to the clt’s internal experiences (though they will observe and interact with the clt).

3rd party

However, when we have concerns about the nature and number of inconsistencies in file, the more sources of info and perspectives we have the more likely we are to be able to resolve them sufficiently and come to a fair and reliable conclusion.

Phone calls related to DAA

We don’t necessarily need a phone call but we do need medical evidence to establish the materiality of substances

However, functional evidence can assist us in determining the extent to which the clt may or may not experience limitations in the absence of the impact of DAA

DAA (ties to the runner)

Ex: can we describe patterns of substance use and how similar or different they are to patterns of the alleged problems over time?

How was their fx prior to substance use? Any differences when using vs during a period of sustained sobriety?

Our Case Study

How will you prepare for the phone call?What questions do you need the

answers to?Are their symptoms in file we should

clarify the impact of?

Our Case Study

Are there inconsistencies in file to clarify? (ex: “it was all a joke”)

Are there any potential 3rd parties identified that you could seek permission to talk to?

What would you do if he threatened suicide?

Questions and Discussion

Questions and ClarificationWhat advice do you have for the training

class (and/or others)?Any favorite questions to ask?

““Focus on Functioning”Focus on Functioning”

Thank YouThank You