1
Focus on Functioning

• when making clarification calls
• Todd Finnerty, Psy.D.

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Welcome and Good Morning

• Objectives

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

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How are you today?

• Objectives

• Describe the practical application of theoretical
  issues impacting the phone call
• Develop and utilize effective techniques for
  clarification/ADL calls

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Reach out and touch someone

• options for functional information
• ADL forms
• Phone call with clt
• Collateral Contact with a 3rd party
• Reports contained in the evidence (school, work,
  treating and examining sources, etc.)
• Adaptive behavior scales (ex VABS)

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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?

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Navigating the tides of change
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• DSM5.org

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Dont be surprised(but not final)

• Intellectual disability instead of MR
• Temper Dysregulation Disorder w/ Dysphoria?
• Aspergers --gt 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

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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?

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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

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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
• Dont ignore how they impact functioning

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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?

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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

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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

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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.

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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.

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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).

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No MDI at discharge?

• He states it was all a joke. He didnt 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.

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Signs and Symptoms?

• The clt actually doesnt 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.

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Proceed w/ a no MDI PRTF?

• It is true that the clts 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? (Well come back to the case study).

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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 cant stop the conversation.
  We need to also ask questions related to specific
  functional areas and abilities.

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Functioning per our Program

• Concentration, persistence and pace
• Social Functioning
• Activities of Daily Living
• Decompensations of extended duration

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Defined as

• We could try to define anything using
  independence, appropriateness, effectiveness and
  sustainability.
• Can you address these in a phone call?

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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.

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Case by Case basis

• How do you know how to ask the right questions
  and what are they?
• Lead a discussion centering around the clts
  allegations and these domains while focusing on
  factors like independence, appropriateness,
  effectiveness and sustainability frequency,
  intensity, duration.

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Other factors to consider

• Consider developmental milestones are they
  engaging in age appropriate activities?

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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?

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Write this down

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

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Write this down

• Did it really happen if it wasnt written down?

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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).

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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.

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Careful!

• You dont know where that clt has been, or where
  theyre going.
• Can you establish a sense of their direction on
  the phone call? (prognosis?)

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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.

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Those who dont 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 clts life and
  a past history of multiple treatment attempts/
  failed treatments may impact their current
  prognosis.

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Our Case Study

• College student, no MDI at d/c
• Would 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?

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For discussion

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

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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 claimants
  problems?

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Finally, the right questions to ask

• The list of all questions is on the next slide

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?
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Use the force

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

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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).

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Socially appropriate?

• If you ask the claimant how are you doing? and
  they say fine, it isnt an indication of
  malingering if they tell their doctor they arent
  fine.
• Building rapport and comfort may help reduce
  responses with limited detail

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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?

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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).

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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.

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Reflective Listening

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

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Reflective Listening

• Helps to build rapport
• Helps 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).

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Reflective Listening

• Ex Claimant I cant seem to get up the nerve
  to be around anyone anymore, I get all hot and
  tense.
• Adjudicator so it sounds like youre anxious
  around other people.
• Claimant yeah, I cant even go in to the store
  anymore, Ive driven there before and just sit in
  the parking lot. My sister shops for me now.

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Follow up questions

• You dont have to move on to a different topic
  until youre 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?

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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?

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Some reasons for making a call

• To obtain general ADLs
• Worsening alleged on recon
• A potential rule out
• 3rd party perspective
• Possible inconsistencies
• Substance use

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General ADLs

• Could make a phone call
• Do 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?

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Whats new?

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

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The potential rule out

• Focus on functioning and dont 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

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Dont try to make your clt drink

• or lead them to water.
• In fact, dont try to feed them at all.
• Ex rep websites/blogs

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3rd party collateral contacts

• General considerations
• Should not be undertaken without permission
• What is their relationship? nature of their
  contact?

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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

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3rd party and inconsistencies

• 3rd partys offer another perspective. however
  no two people should ever be expected to see
  things exactly the same way.
• 3rd partys also do not have access to the clts
  internal experiences (though they will observe
  and interact with the clt).

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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.

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Phone calls related to DAA

• We dont 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

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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?

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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?

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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?

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Questions and Discussion

• Questions and Clarification
• What advice do you have for the training class
  (and/or others)?
• Any favorite questions to ask?

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Focus on Functioning

• Thank You