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The Doctor’s Office
Psychology: Interview with
Bruce T. Leckart, Ph.D.
In this series
featuring medical professionals
in the workers’ compensation system,
Marjory Harris interviews psychologist
Bruce T. Leckart, Ph.D. on causation of
psych disability and apportionment.
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HARRIS: Dr.
Leckart, you have had a long career in both the academic world
and forensic psychology and are a Qualified Medical Evaluator and
expert witness. You have written a
book, “Psychological Evaluations
in Litigation: A Practical Guide
for Attorneys and Insurance Adjusters," and
you also publish a newsletter. In the foreword to your book you
state, “I have adopted an
attitude of “I’ll call
it the way I see it and let the
chips fall where they may.”’
How
does a psychological evaluator avoid subjectivity and bias?
LECKART: My
motto is simply, “Find the
truth, tell the story.” Subjectivity
and bias only become issues when the examiner has another agenda,
such as making one of the lawyers in
an AME case happy or “splitting
the baby” to give “something to everyone.”
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HARRIS: In
your book you discuss the five sources of information from which
psychologists draw diagnostic conclusions. What evidence do you
most rely on? Does it matter
whether there is testimony under oath,
in the form of depositions or
declarations?
LECKART: The answer to the
first question is that I
don’t put an emphasis on any specific
source but try to look at the whole picture. I let the data tell
me what is most important. The answer to the second question is
that except for assessing an
applicant’s credibility, deposition
testimony is typically not useful
since attorneys rarely ask questions
that generate meaningful psychological information. This is to
be expected, since an attorney’s expertise is in the law,
not psychology.
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The Five Sources
of Information:
I. Mental Status Examination
II. Life History and
Presenting Complaints
III. Psychological Testing
IV. Review of
Medical Records
V. Collateral Sources of Information
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HARRIS: What
process do you follow for analyzing
causation of injury?
LECKART: After
first determining
that there is a DSM-IV-TR psychological disorder I look at all
of the factors I can imagine that could conceivably have played
a role in causing that disorder.
Then I estimate the likely relative
contribution of each factor. Ultimately, the decision is based
on my subjective estimate after
considering the objective data.
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Ultimately, the decision is based
on my subjective estimate after considering the objective data |
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HARRIS: Do
you follow a different process when
analyzing causation of permanent
disability, or
“apportionment”?
LECKART: No.
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HARRIS: Are
you influenced by theories of
developmental psychology when determining
apportionment?
LECKART: No. I
think developmental
events are over-rated with regard
to apportionment. I do not believe
that every aversive event in a person’s life necessarily
contributes to permanent psychiatric disability or has made them
more vulnerable to an industrial injury. In fact, there is a good
deal of psychological research
supporting the idea that, “what
doesn’t kill you makes you stronger.” Nevertheless,
although in some cases aversive events make people stronger, in
other cases it makes them weaker. Again, this must be considered
on a case-by-case basis.
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| Developmental events are
over-rated
with regard to apportionment. |
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HARRIS: Some
psychiatrists have been
apportioning based on the underlying orthopedic
or pain disorder, so if the orthopedic evaluator says that there
is 20% apportionment, the psychiatric evaluator says, since the
psychiatric disorder flows from the physical disability, 20% of
the psychiatric disorder is apportionable. I do not see any logic
in that, or science to support that
approach. Do you?
LECKART: The short answer
is no. The long answer involves considering all of the causes of
the permanent psychiatric disability. In every orthopedic case
I can recall, the
individual’s permanent psychiatric
disability
was produced by multiple factors
including the orthopedic disability,
the individual’s pain and a
variety of psycho-social factors
including, but not limited to, their inability to work at their
previous level and disruptions in their personal lives. However,
orthopedists only apportion the
orthopedic disability. Accordingly,
as a psychologist it is necessary to take into consideration all
of the other factors impinging on
the person’s psychological
status.
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HARRIS: Do
you think that the current rating
system for psychiatric disorders,
based on GAF, makes more sense than the one we used before based
on the 8 work functions?
LECKART: Absolutely not. The
GAF is substantially flawed. In
fact, when one reads the definition
of most of the GAF scores found on page 34 of the DSM-IV-TR they
state that the doctor should base
their judgment on the patient’s
“symptoms.” Now
just about everyone knows that the word “symptoms” is
synonymous with
“complaints.” Obviously, while
I’ve
seen it done, it is shear folly to base a GAF score solely on the
patient’s complaints. Clearly, the DSM-IV-TR is flawed in
that it doesn’t state that
the patient’s “signs,” i.e.,
those observations made by the doctor, are relevant. Another flaw
in the GAF is that it doesn’t adequately define the various
levels of occupational impairment,
such as “slight,” “some,”
“moderate,” and
“serious,” but
leaves it up to the doctor to
define those terms any way they want.
The eight basic work functions were
clearer. The only problem with
that system was that there never was a clear definition of the
levels of impairment such as “slight,” “very
slight,”
“moderate,” etc. If those were
adequately
defined that system would be far
superior in terms of its reliability
in that two doctors looking at the same applicant would be more
likely to agree on the applicant’s disability.
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The
Global Assessment of
Functioning (GAF) is a numeric
scale (0 through 100) used by mental health
clinicians
and doctors to rate the social,
occupational and psychological functioning
of adults. The scale is presented and described in the DSM-IV-TR
on page 34. Children and adolescents
under the age of 18 are evaluated
on the Children’s Global Assessment Scale, or C-GAS.
91-100
Superior functioning in a wide range of activities, life's problems
never seem to get out of hand, is sought out by others because of
his or her many qualities. No symptoms.
81-90 Absent or minimal symptoms,
good functioning in all areas, interested and involved in a wide
range of activities, socially effective, generally satisfied with
life, no more than everyday problems or concerns.
71-80 If symptoms
are present they are transient and
expectable reactions to psychosocial
stresses; no more than slight impairment in social, occupational,
or school functioning.
61-70 Some mild symptoms OR some difficulty
in social, occupational, or school
functioning, but generally functioning
pretty well, has some meaningful
interpersonal relationships.
51-60
Moderate symptoms OR any moderate
difficulty in social, occupational,
or school functioning.
41-50 Serious symptoms OR any serious impairment
in social, occupational, or school functioning.
31-40 Some impairment
in reality testing or communication OR major impairment in several
areas, such as work or school, family
relations, judgment, thinking,
or mood.
21-30 Behavior is considered influenced by delusions or
hallucinations OR serious impairment in communications or judgment
OR inability to function in all areas.
11-20 Some danger of hurting
self or others OR occasionally fails to maintain minimal personal
hygiene OR gross impairment in communication.
1-10 Persistent danger
of severely hurting self or others OR
persistent inability to maintain
minimum personal hygiene OR serious
suicidal act with clear expectation
of death.
0 Not enough information available to provide GAF. |
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HARRIS: Some
evaluators are using Chapter 14 of the AMA Guides, which deals
with mental and behavioral disorders, as an alternative method
of evaluating psychiatric disorder,
although the rating
schedule itself
states, “Psychiatric impairment shall be
evaluated
by the physician using the Global Assessment of Function (GAF)
scale ….” (p. 1-12) Do you find that chapter at all
helpful, or is the GAF sufficient
in all cases?
LECKART: I do not find that
chapter helpful in that there is nothing in its contents that can
assist me in conducting an evaluation or thinking about a case
and coming up with a disability rating that makes more sense than
a realistic and thoughtful use of the GAF.
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HARRIS: The
revision of the permanent disability rating schedule required every
five years by Labor Code §4660 is long overdue. If you were
asked by the AD to designate a system for evaluating work-related
psychiatric disorders, what would be your recommendation?
LECKART: I would go back to
the Psychiatric Protocols and the eight basic work functions and
attempt to define the levels of impairment.
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Bruce T. Leckart, Ph.D., QME
Lic.
Psychologist
Psychiatric and Psychological Evaluations & Treatment
11340 Olympic
Boulevard, Suite 303
Los Angeles, California 90064 - 1613
(310) 444-3154
FAX (310) 444-3144
DrLeckartWETC@gmail.com
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