Download A “Focus on Functioning” Paradigm

“Focus on Functioning”
when making clarification calls
Todd Finnerty, Psy.D.
Welcome and Good Morning
• Participants will be able to apply
an approach to making phone
calls which attends to the impact
allegations and symptoms have on
the 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

Reach out and touch someone
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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)

Benefits of a call?
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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.org
Don’t be surprised…(but not final)
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Intellectual disability instead of MR
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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
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DSM-5 expected May, 2013
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Diagnoses may change, but your clt will
still avoid crowds
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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).”
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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
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Why am I here?

Is listing signs and symptoms sufficient
for you to accomplish a disability
determination?
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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
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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
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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
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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?
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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 6065.
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.
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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).
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The devil is in the details
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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 pace
 Social Functioning
 Activities of Daily Living
 Decompensations of extended duration
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Defined as:
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We could try to define “anything” using
independence, appropriateness,
effectiveness and sustainability.
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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.
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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
clt’s 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…
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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?
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Write this down…
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Regardless of what questions you asked,
your best phone call was the one you
documented well
Write this down…
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Did it really happen if it wasn’t written
down?
Observe and report
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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?
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Are you an adjudicator or a biographer?
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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?)
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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 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/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…
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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?
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Finally, the right questions to ask…
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The list of all questions is on the next
slide…
?
Use the force…
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There are lots of ways to paint a picture,
and no one set of questions that all have
to be asked.
Be Inappropriate.
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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
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Our Case Study
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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).
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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
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Make statements summarizing back
main points that the person has made
without including significant judgments
on your part
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 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.”
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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?
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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?
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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
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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
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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 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).
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3rd party
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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
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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