Over the last few decades, psychological testing instruments have come to play a significant role in determining the outcome of legal cases. This includes tests that are relied upon to determine functional impairments and injury-related disability benefits, parental fitness in child custody matters, access to mental health services based upon clinical conditions, litigant veracity such as malingering and deception, and competence in criminal and immigration matters. Given the prominent and often crucial role played by psychological tests in judicial decision-making, it is interesting to note that attorneys rarely challenge psychological expert assessment evidence.

While judges serve as the gatekeepers to make certain that only sound expert opinion testimony is allowed as evidence, both they and the legal professionals that appear before them in court are not trained to analyze the validity of psychological tools. Neither are they prepared to evaluate the scientific merits of various expert psychological methods more generally. According to the National Research Council’s research, courts routinely admit evidence with questionable scientific foundations, which increases the risk of error and thereby threatens the integrity of decision-making in the legal system. 

As Dr. Neal explains, “Even if lawyers or experts are aware of a tool’s weaknesses, they may not push the issue if the tool is one of many bases for an expert’s opinion. As noted, appellate courts often adopt the view that, if suspect evidence is merely a “piece of the puzzle,” concerns about validity are undercut”. She continues, “This point of view can fail to consider the influence of the allegedly defective puzzle piece on the opinion as a whole and fails to consider the validity of the other pieces. Arguably, the more responsible position is the fact that a particular test result is not dispositive does not eliminate concerns about validity.”

The authors admonish “mental health practitioners to be more discerning in the choices they make with regard to assessment tools used in forensic cases (and) attorneys to challenge and judges to scrutinize psychological assessment experts more frequently.” I wholeheartedly agree.

In addition to the potentially adverse impact of embracing results from tests with suspect psychometric integrity, there are other serious challenges that threaten the usefulness of psychological testing. These include issues related to test selection, methods, data interpretation and how test results are integrated into the broader forensic examination.

Neal, Tess MS, et al. “Psychological Assessments in Legal Contexts: Are Courts Keeping “Junk Science” Out of the Courtroom?.” Psychological Science in the Public Interest 20.3 (2019): 135-164.

This was the Northridge earthquake in Los Angeles, a proverbial act of God, as insurance contracts describe it, whose epicenter was just a few miles from our home. The 6.7 magnitude tremor lasted only 20 seconds, but it seemed like an eternity. Millions of people instantly were united in a state of panic. Over the next many hours as we cowered under a door frame in our hallway, attempting to learn through the static filled noise from my old transistor radio what was happening outside our home, neighborhood and the world at large, we were frozen in fear, worried what all this meant, if our demise was imminent, and perhaps most significantly, wondering if the next jolt was merely an aftershock, or the prelude to “the Big One”, which we had been told for decades was long overdue.  This was my introduction to mass disaster, and the mass psychological trauma that followed. A perfect diabolical cocktail of shock, disbelief, emotional numbness, and an invasive mental fogginess akin to severe concussion.

The next days, weeks and months were beyond surreal. Massive power outages, contaminated water supplies, food shortages, collapsed highways and infrastructure, decimated local economies, dozens of fatalities and innumerable injuries, and widespread homelessness. Curfews were imposed and the National Guard was deployed. Over time, the shock and disbelief transitioned into sadness and uncertainty, and then eventually acceptance and the resolve to rebuild. Although the mobilization was swift and life returned to a new normal, the mass PTSD lasted well over a year.

But we believed in ourselves and came together as a society, persevered, and we built anew — achieving and improving upon that which was. We became stronger, wiser, and better prepared for the next challenge. The same holds true of my newly adopted city, Chicago. From the flames of the great fire of 1871, a world class city arose from the ashes and continues to thrive today. Such is humanity.

And so here we are, 26 years after the earth trembled, facing a new challenge, along with billions of our neighbors. As a practicing psychologist today as I was in 1994, I share with you below some insights into coping with trauma. People experience a variety of symptoms in the face of traumas, and these feelings by and large are a normal part of grieving and recovering. They may include:

• Having trouble falling asleep or staying asleep
• Experiencing sadness, depression, hyperactivity, irritability, or anger
• Having no feelings at all or feeling numb
• Feeling a lack of energy or feeling exhausted all the time
• Noticing a lack of appetite or the opposite, eating all the time
• Having trouble concentrating or feeling confused
• Experiencing social isolation, or reduced or restricted activities
• Thinking no one else is having the same reactions as you
• Having headaches, stomach aches or other body pains
• Misusing alcohol, tobacco, drugs, or prescription medications to cope

Sometimes friends and family may respond to the identical trauma differently than you. There is no right or wrong way to deal with a traumatic event. You may want to:

• Stay alert for signs of stress in others, and then listen to them and allow them to express their feelings
• Respect the fact that others may respond to trauma differently than you do so seek ways to support them that work with their own unique experiences and responses
• Give support and companionship by offering understanding, patience, and encouragement, and by running errands and sharing resources as you can
• If a friend or family member needs a counselor’s help, assist them in getting that help, including making an appointment and facilitating their attendance
• Take any remarks about suicide seriously and ensure the person discusses these feelings with his or her doctor immediately. Go with the person to see a doctor or counselor if necessary, and if you believe immediate self-harm is possible, call 911

Finally, the healthiest thing you can do for yourself and your loved ones is to be on the lookout for changes in your own feelings and moods. Take care of yourself so you can take care of others. Consider trying to:

• Keep to your usual routine
• Take the time to resolve day-to-day conflicts so they do not add to your stress
• Do not shy away from situations, people and places that remind you of the trauma
• Be mindful and recognize that you cannot control every aspect of your life
• Find ways to relax such as breathing exercises, meditation, mindfulness, calming self-talk or soothing music
• Prioritize self-care by eating well-balanced meals and getting a good night’s sleep
• Turn to family and friends for support, and talk with them about your experiences and feelings
• Engage in fun and restorative activities, including exercise, leisure, recreational and social activities
• Be patient and take things one day at a time 
• Limit exposure to television and social media content about the disaster since overexposure can increase distress
• Remind yourself and others that its normal to have many different feelings, as well as “good days” and “bad days” as a natural part of coping
• Recognize the need for trained help, and call a mental health specialist

We continue to confront the alien invasion that is COVID-19. But as always, we shall overcome. As Olympian Dan Jansen said of persistence, “When you have exhausted all possibilities, remember this… you haven’t.” Take care of yourself, take care of each other, and remember, as my mother, of blessed memory,  used to say when facing a challenge, the sun will come out tomorrow.

This also holds true for attorneys that litigate clients’ mental and physical injuries as they too repeatedly interface with persons laboring to cope with both physical and psychological impacts from their injury and regain balance in their lives. Since the duration, complexities, and psychological and behavioral reactions by the parties involved in processes of marital dissolution or recovery from injury are unpredictable, it is important to ensure that those clients have sufficient emotional support so they can emerge from litigation with good physical and mental health to begin new and fulfilling lives.

Attorneys, regardless of specialization area, usually can recognize the presence of unhealthy feelings and behaviors when interacting with emotionally distressed clients, and in response they by and large strive to connect them with mental health professionals. However, such efforts often are unsuccessful for many reasons. This is a two-part article in which I present four strategies intended to increase the chances that your clients successfully obtain the psychological support they need. Part 2 will be delivered to your Inbox next week.

Strategy 1 – Be proactive by establishing a long list of competent mental health professionals, be they social workers, psychologists, or psychiatrists, to who you can refer your clients at a moment’s notice. There is a drastic shortage of qualified clinicians in Chicagoland, and therefore many clinicians’ practices are full and cannot accommodate new referrals. Clients requiring a quick consultation or those in crisis cannot wait for a clinician’s availability. Thus, ensure you have many referral options available.

Strategy 2 – Play an active role in facilitating contact between your client and the clinician. Where possible, reach out to the selected clinician in advance to explain the nature of and reason for the referral, as well as its level of urgency. Ensure that both the clinician and client have one another’s full contact information, and that each party is accountable to you to make the connection in a timely fashion.

Strategy 3 – In medical settings, when physicians refer a patient to a behavioral health professional, there is a 50%-80% chance that the patient will not show up for the first appointment. One way of markedly improving those odds is to provide a “warm handoff”, meaning an in-person introduction of the therapist to the patient by the physician. The rationale of the warm handoff is that the trust and rapport a client has in the physician can then be conferred directly to the treating therapist, thereby reducing any worry, resistance or stigma that might otherwise interfere with the client’s follow through in attending the intake appointment.

There is no reason to believe that the no-show rate for the clients you refer for therapy is any better than the rate for physicians. For attorneys, since the therapist is not co-located in or even closely situated by your office, an immediate in-person warm handoff usually is hindered. However, one instead can consider facilitating a warm handoff by scheduling a visit by the psychologist at your office with your client present or offering a virtual warm handoff such as a three-way phone call or video chat, allowing for a real time introduction of your client to the therapist. Applying this extra effort may increase the chance that your client will initiate treatment with the therapist.

Strategy 4 – As the full benefits of a warm handoff in building an initial bond between a client and a therapist continue to be researched, recent literature suggests that a critical factor in determining whether or not your client attends therapy is the time delay between your referral and the actual first appointment. In other words, if the therapist can see your client right away, within a day or two for example, and even if only for a phone call or brief visit at first, there is a much greater likelihood that the client will successfully engage in the psychotherapeutic services needed to help him or her successfully navigate a divorce or other litigation process.

In the meantime, your mental health during this challenging time is as important as your physical health – they are inexorably tied together. As a society, we never have attempted to do what we now must do… to physically distance ourselves from that which we cherish most in life… people, our greatest source of positive psychological wellbeing. Remember, social “distancing” does not mean socially “disengaging”.

In that light, I encourage everyone to try to maintain as much normalcy in one’s daily routines as possible, and of course to rigidly comply with federal, state and local directives. In fact, consider the new guidelines to be “rules”.  We seemingly are in this for the long-haul and we need to put into place plans to maintain this new pattern of life for a possibly prolonged period. Be flexible, uplift and support others, and stay positive.

Our regular routines have been disrupted, including our access to meaningful activities, sensory stimuli and social engagement, we may be experiencing financial strain from being unable to work, and we may be unable to use our usual stress coping strategies such as going to the gym or attending religious services. The American Psychological Association notes that during a period of social distancing, quarantine or isolation, one may experience:

• Fear and anxiety
• Depression and boredom
• Anger, frustration or irritability
• Stigmatization

Psychological research offers insights into how best to cope with these difficult conditions. Consider implementing the following strategies:

• Limit news consumption to reliable sources and remember that too much exposure to media coverage of the virus can lead to increased feelings of fear and anxiety
• Create and follow a daily routine to preserve a sense of order and purpose
• Stay virtually connected with others through phone calls, text messages, video chat and social media to access social support networks
• Maintain a healthy lifestyle by getting enough sleep, eating well and exercising
• Apply stress management strategies to stay positive by realistically assessing your actual concern and your ability to cope, and try not to catastrophize but instead focus on what you can do and accept the things you can’t change

Anyone who’s ever been on a ship in stormy seas knows that the best way to avoid illness is by gazing at the horizon. Focus on where we’re going, not the waves now crashing in front of us. We all will get through this together, and we’ll all arrive safely at our ports!

Implementation of these recommendations requires that clinicians obtain exceptionally thorough psychosocial histories and conduct detailed assessments of patients’ activities and functional abilities. This includes not only the documented activities that the patient might perform today, but also the patient’s capacity to do the same in the near future. All realms of a patient’s lifestyle must be explored with exhaustive scrutiny – from activities of daily living, to family relations, to recreational pursuits, and beyond. In my own IME practice, for example, over the last 20 years I have been using a proprietary decision-support instrument, the Functional Capacity Assessment Profile©, to help guide this investigation process. I will review this tool in my next column.

Once that thorough evaluation is completed, the clinician must then rate the patient’s permanent psychiatric impairment level using a rating schedule. Extending the discussion from my last column, below I explore several of the psychiatric impairment rating schedules available historically, using California’s workers’ compensation reform experiences for illustrative purposes. Doing so offers the reader insights into the ongoing efforts to provide a more useful and meaningful standard for rating permanent emotional disability in injured workers and others.

Prior to the introduction of the DSM’s Global Assessment of Functioning (GAF) scale some 25-30 years ago, mental health clinicians by and large were relegated to define emotional impairment solely in terms of a patient’s symptoms and diagnosis, with relatively minimal attention paid to describing the specific dysfunction associated with any given diagnosed psychiatric condition. The GAF instead offered a means to provide a subjective rating of the social, occupational, and psychological functioning of the individual, using a numeric scale from 1 through 100. Some examples of the symptoms associated with various GAF scores are below:

91-100:    No symptoms. 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 positive qualities.

51-60: Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social or occupational functioning (e.g., few friends, conflicts with peers).

1-10: Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death

The GAF was deservedly highly criticized for its lack of standardization, its reliance on subjective information, its lack of validity and reliability, its flawed attempt to generate a single score from the three aforementioned dimensions of emotional well-being, and more.

The California Department of Industrial Relations then mandated the use of the ‘Eight Work Functions” to rate psychiatric impairment, which included the:

1. Ability to perform simple and repetitive tasks
2. Ability to maintain a work pace appropriate to a given workload
3. Ability to perform complex and varied tasks
4. Ability to relate to other people beyond giving and receiving instructions
5. Ability to influence people
6. Ability to make generalizations, evaluations or decisions without immediate supervision
7. Ability to accept and carry out responsibility for direction, control and planning
8. Ability to accept and carry out responsibility for direction, control and planning

The first three impairments above were given greater weightings than the last five for rating purposes. A fixed 7-point severity rating system was used: Minimal (discomfort but not disabling), Very Slight (detectable; 5%), Slight (noticeable; 5%-10%), Slight to Moderate (10%-20%), Moderate (marked; 20%-30%), Moderate to Severe (30%-50%), and Severe (unable to perform work function; 50%+).

While this rating schedule at least attempted to better define impairment, it was intentionally limited to just vocational-related activities. Moreover, this scale was subject to most of the same criticisms as the GAF. However, to its credit, the scale was characterized in the language of abilities, and it also included specific behavioral criteria in a modest attempt to operationally define each category.

The Eight Work Functions schedule was “abandoned” after a relative short time, with a recommended return to using the GAF. Then the Psychiatric Impairment Rating Scale in the AMA Guides to Permanent Impairment was introduced. These Guides focus on providing impairment ratings, using a five-point severity scale, in four areas of functioning:

1. Activities of daily living, which includes self-care, personal hygiene, communication, ambulation, travel, and social and recreational activities
2. Social functioning which refers to the ability to get along with others and communicate effectively
3. Concentration, persistence and pace, which is defined as defined as the ability to sustain focused attention sufficiently to complete tasks in a timely manner
4. Adaptation which refers to repeated failure to adapt to stressful circumstances

Sadly, most of the criticisms associated with the other two rating schedules also apply to the Psychiatric Impairment Rating Scale. On the other hand, the Psychiatric Impairment Rating Scale does at least attempt to provide a more global assessment of the patient’s daily adaptive capacity rather than work-related abilities alone.

And so remains our current state of affairs. Supposed increased refinement over time has not necessarily led to the desired outcome of an accurate and consistent permanent psychiatric impairment rating schedule with an underlying evidence-based foundation. We simply will have to wait and see what the next “solution” offers.

Psychologists and psychiatrists begin their IME evaluations with the end goal in mind… specifically, to stay mindful that the primary objective of the examination is to investigate and describe the patient’s functional capacity, not the presenting symptomatology.

When I grew up in Los Angeles in the 1950s and 1960s, the primary sources of my knowledge were my parents, teachers, newspapers, limited television, and the public library. In that era, we greatly respected the information available to us, in part because it was so hard to come by. Today we live in an entirely different world. Rather than struggling to find sources of accurate and helpful information, we instead are bombarded with information, primarily the result of the Internet.

The Internet has dramatically altered the world and our society in ways that we don’t yet fully understand or appreciate. Furthermore, its future course and impact is entirely unpredictable. I absolutely am not a Luddite, fearing the impact of technology on society; in fact, I have been immersed in computer-related technology since my 20s. However, I do feel that it is important that the professional community be aware that the influence of the Internet is far from benign. Indeed, I believe that it presents challenges unlike anything that civilization has yet to experience and confront.

When we have a question that needs answering and no one trustworthy is immediately available to provide an answer, we typically seek answers through an Internet search engine such as Google, Bing, Yahoo, YouTube, and more. We do so largely because it is easy, convenient and instantaneous. Perhaps that fact alone should raise red flags.

In the discussion that follows, I use “Google” as a generic descriptor for all Internet search engines, not only Google per se. When I Googled the words “no-fault”, it returned 55,100,000 results in 0.39 seconds. The word “custody” returned 81,800,000 results in 0.41 seconds. The term “judgment” returned 177,000,000 results in 0.33 seconds. At ten websites listed per page of results, this means that there are nearly 18 million pages that list websites regarding “judgments”. And how many pages of Google results does the average person typically review? 2? 3? 5? 10?

We assume that the most important information is going to be found in the first few pages of a Google search, but is it true that the most accurate and educational information about the topic is actually present in those first few pages of results? Are we wise in ignoring the remaining tens of millions of pages of information?

One of the most significant shortcomings of Google and all such search engines is that there is no measure of veracity tied to any of the webpages identified as relevant to the search. Thus, there is no way to determine if the information that you obtain from your search is completely accurate and truthful. The exactness of a person’s “knowledge” about a topic drawn from a Google search may depend upon the degree of truthfulness of the information contained in just the first few pages of results.

It is useful to understand how a website manages to reach the top of the list in a Google search, among the millions of webpages on a topic, something that Google calls “Pagerank”. Becoming listed among the first couple of pages of results is based upon many factors, the most important of which is the number of other Web pages that link to the page in question. In other words, the more that other websites mention your website, the higher on the list your website goes. So, if a particular website containing misinformation happens to be referenced on the websites of many equally misinformed individuals, then that website containing inaccuracies potentially can appear high up on the Google list.

Since most people review only the first few pages of Google results, their base of knowledge, which they believe to be the “truth” about a topic, actually can become somewhat corrupted and biased. Their view of the “truth” is now based in part upon possible distortions simply by taking advantage of the convenience and simplicity of an Internet search.

Why is this important to us? Because we do not know how to properly filter information provided to us. We don’t know how to separate the relevant from the irrelevant, how to separate truth from fiction.

In his book, “Thinking Fast and Slow”, Nobel Prize winning author Dr. Daniel Kahneman exposes how and why our natural intuition is extremely biased. Our brains are comprised of two thinking systems, one that thinks fast, and one that thinks slowly. The first system that Thinks Fast operates automatically, intuitively, involuntary, and effortlessly — like when we drive, read a happy facial expression, or recall our age. The second system, one that Thinks Slow, requires slowing down, deliberating, solving problems, reasoning and analyzing, focusing, concentrating, considering other data, and not jumping to quick conclusions. The goal for us, expressed in Kahneman’s book, is how “to recognize situations in which mistakes are likely, and try harder to avoid making significant mistakes when the stakes are high”.

Thinking slow affects our bodies, our attention, and our energy. Because thinking slow takes work, we are prone instead to think fast, taking a path of least resistance. Dr. Kahneman tells us that “laziness is built deep into our nature”. Harvard neurologist, Dr. Steve Miller, who wrote about how our thinking process causes bias, remarked that when it comes to making decisions, “We are hard-wired to get it wrong”.

In other words, we human beings, by our biological nature, often make significant mistakes because we don’t want to exert our brains and think deeply, in case we might unnecessarily waste energy. This tendency to draw conclusions rapidly, without fully considering and exploring a substantial amount of the information available to us, and to make impulsive and often hasty decisions based on that information, occurs regardless of the source of that information. It just happens to be a natural fit for our Google-esque World, creating a perfect storm wherein we are overwhelmed with information from an Internet search, we review only a fraction of that data, we have no effective way of determining what is true and what is false, and then we make quick decisions based upon that set of information.

Our propensity to permit machines to do our thinking for us can result in changes in our understanding of the world around us and may adversely affect our effectiveness as professionals. For instance, a recently published study from the University of Waterloo in Canada found that people who spent more time using the search-engine function on their smartphones actually showed a decrease in mental ability and a lowered willingness to analyze information. Thus, we legal and mental health professionals remain highly vulnerable to the introduction of potential bias into our thinking and decision-making processes by virtue of doing something as seemingly innocent as performing an Internet search.

We professionals develop a heightened sense of awareness of our vulnerability to the types and sources of information that potentially can unfavorably influence our decision-making, that we recognize first and foremost the situations in which wrong decisions can have the greatest adverse impact on that which we care about most so that we engage in deep rather than rushed thinking, and that we remain constantly vigilant to those environmental factors that can interfere with our pursuit of truth.

As I have emphasized in previous posts, the term emotional disability is not so much about the emotional element, in other words, the psychological symptoms and affiliated diagnoses with which we all are familiar, such as anxiety and depression. Instead, it is about the disability component, the presence of impairment in one’s capacity to function with maximal effectiveness to meet one’s daily obligations and needs. If someone allegedly feels severely depressed but that depression does not adversely interfere with her or his regular routine, then how truly debilitating is it? 

We in the mental health profession are unable to directly gauge the significance of an emotional symptom with indisputable precision because emotions are subjective and internalized experiences. Feelings and sensations are not readily amenable to exact measurement. However, an externalized representation of the emotion, specifically, a person’s regimen of behaviors, can be observed and thus more reliably measured.

Still, the process of observing and measuring behavior to assess for the presence of emotional disability is easier said than done. As the famous psychologist B.F. Skinner once remarked, “Behavior is a difficult subject matter, not because it is inaccessible, but because it is extremely complex. Since it is a process, rather than a thing, it cannot be held still for observation. It is changing, fluid, evanescent, and for this reason it makes great technical demands upon the ingenuity and energy of the scientist.” 

In my 2015 blog entitled, “You Can’t Rate Psychiatric Impairment If You Don’t Assess It”, I described the many attempts by the mental health profession to institute a user-friendly, valid and reliable scale to rate emotional disability resulting from physical and psychological traumas. These include the:

1. DSM’s Global Assessment of Functioning (GAF), a 1-100 subjective rating scale,
2. Eight Work Functions measure that provided a 7-point severity rating scale designed to rate work-related behaviors only, and
3. Psychiatric Impairment Rating Scale in the AMA Guides to Permanent Impairment that offers a five-point severity scale to rate four areas of functioning: Activities of daily living, Social functioning, Concentration and Adaptation.

Unfortunately, all three of these scales are vulnerable to the deserved criticism that they are psychometrically flawed, meaning that they lack sufficient validity and reliability to provide useful and meaningful information to the clinician. This did not, however, stop these tools from being used on a regular basis.

In my most recent blog entitled, “Exploring the Minefields of IME Disability Examinations”, I commented that there are no validated psychological tests that directly assess global functional impairment in adults. However, I also noted that there is at least one exception, the Functional Capacity Assessment Profile, which this author initially developed and preliminarily validated some two decades ago, but never published in a peer-reviewed journal.  I promised to share details of that instrument in a new article. 

The global assessment of functioning in adults actually has a very long history, dating back to no later than the 1950s, with instruments such as the Vineland Adaptive Behavior Scales and the AAMD Adaptive Behavior Scale. However, these tools were designed solely for the purposes of assessing persons with intellectual and developmental disabilities, including autism. Yet, for reasons that are unclear, such conceptual models and technologies never were embraced by and transformed for application in the non-developmentally disabled world. One possible reason from this failure may lie in the fact that during that era, the assessment of adaptive behavior in the disabled population largely was the sole purview of psychologists, whereas psychiatrists, who still owned most all other realms of mental health services then, continued to employ a medical model that focused on assessing symptoms and providing diagnoses, rather than measuring a patient’s ability to function in his or her daily life.

In the mid-1990s, my colleague, Dr. Larry Feinstein, and I independently undertook the challenge to develop an instrument that could measure global emotional functioning in “normal” adults. This effort reflected an attempt to offer an alternative and more scientifically-grounded instrument to the mental health community relative to the simplistic GAF scale of the DSM. The multiyear project eventually produced the Functional Capacity Assessment Profile (FCAP), which underwent significant field testing and validation and was privately published.

While the instrument requires further statistical validation and therefore should be used as a qualitative rather than a quantitative tool at this time, the descriptive data from FCAP can readily serve as a supplement to clinical observational and self-report information. The instrument’s norms were established over an approximately 20-year period of time and incorporate a population of approximately 4,000 individuals from across the U.S., including mental health outpatients, general medical outpatients, and workers’ compensation claimants.

I believe that at minimum, the FCAP continues to serve as not only a viable conceptual model for understanding global functioning, adaptive behavior and psychological disability, but as a helpful decision-support tool. It is here that the FCAP’s role in evaluating emotional impairment in forensic matters comes into play. As I have argued above, emotional disability is not simply the presence of symptoms, but more relevantly, it is the reduced capacity to function effectively in our respective environments. Specifically because FCAP is behaviorally based, it therefore can be used as a semi-structured interview tool to guide and prompt clinicians, both mental health professionals and primary care doctors for that matter, to explore patients’ capacity to function in their daily lives, and to help identify areas of possible disability that are worthy of further clinical investigation and inquiry.

Briefly, the Functional Capacity Assessment Profile is a standardized, 55-item self-report inventory that describes an individual’s psychological well-being in terms of the ability to function effectively in daily life. These 55 items function as behavioral markers that reflect a person’s capacity to perform critical social and independent living skills, across a comprehensive array of eight behavioral domains:

• Emotional Management
• Communication and Social Involvement
• Health Behaviors
• Personal Management
• Leisure
• Self-Care
• Family Care
• Job-Related

The information generated from this type of instrument provides the attorney with a broad overview of a person’s scope of functional capabilities, highlighting areas where a client is functioning well and areas where there might be behavioral limitations. In this way, the otherwise nebulous concept of a “mental disability” becomes much more transparent to the legal profession. Improved clarity emerges when one is cognizant of how an emotional “impairment” is defined and measured, allowing mental health and legal professionals to speak the same language. This thereby provides the attorney with more advanced ammunition to test the foundational proficiencies of the expert witness.

I recommend that attorneys practicing in areas of law in which clients’ functional abilities are relevant to the legal case develop a keen understanding of the theoretical concepts and practical aspects of emotional impairment. A short study of the FCAP, as a model, can serve as an effective way of quickly developing such an understanding. 

The Triple Aim model whose purpose is to enhance the U.S. healthcare system requires achieving three interdependent goals: improving the experience of care, improving the health of populations, and reducing the per capita costs of health care. There is an immediate and urgent need to expand Americans’ access to affordable and high quality mental health care and addiction treatment services, and especially in underserved populations.

Since the introduction of managed care models in the U.S. healthcare system in the 1990s, there has been an ongoing tension between those parties representing the clinical side of healthcare that focus on addressing patients’ clinical care needs, and those representing the business side of healthcare that focus on addressing the financial needs of healthcare delivery systems. This dichotomy is both artificial and untenable. 

Despite the intentions of so many well-meaning mental health professionals, the current barrier of insufficient access to quality mental healthcare services is in part the result of pervasive inefficiencies inherent in behavioral health organizations’ clinical and business operations, an
absence of strategic frameworks to drive growth, and failed policies and practices that often render provider groups financially unsustainable let alone capable of expanding service capacity to meet broader population healthcare needs.

When a behavioral healthcare organization is faced with cashflow management challenges, one consideration is to partner with a consulting firm that specializes in facilitating process improvement through enhanced reimbursement models, optimized clinical delivery systems, efficient business operations, and strategic organizational initiatives. A revenue cycle management (RCM) company can serve as a valuable asset for maximizing income. A comprehensive scope of revenue boosting services from RCM companies may include patient benefits verification, prior authorizations, initial and concurrent reviews, charge capture, claims and denial management, effective payer contract management, collections, and provider credentialing, all of which are crucial to ensure proper clinical, operational and fiscal functioning. 

One should strive to retain revenue cycle management professionals that have proficiencies specific to behavioral health. The degree to which these consultants also can bring expertise and deep experience in behavioral health services delivery systems design and management, as well as organizational behavior management and transformation, decreases the likelihood that implementation of revenue-related operational changes will adversely impact the overall functioning of the organization.

In parallel, a consulting organization that can help eliminate revenue leakage and enhance revenue integrity nicely complements efforts to improve revenue capture processes. The course of reducing leakage and shoring up systems that foster revenue stability may include addressing a variety of operational components such as referral, intake and scheduling processes, the overall scope of programs and services, application of best clinical practices, organizational leadership and communication, strategic planning and decision-making, human capital and performance management, data management and systems integration, documentation and compliance, payer relationships, and utilization management. Moreover, all these factors must be solidified and optimized if the organization eventually intends to scale.

As a boutique consulting firm, we advise the behavioral healthcare community on the strategies and resources needed to foster growth. Our assessment model is client-centric, data-driven, multidimensional and inclusive. We apply an integrated approach to help behavioral healthcare organizations maximize cashflow and minimize the dollars that otherwise would be left on the table absent optimizing clinical and business operations. This may be achieved through a combination of clinical services expansion strategies, elimination of friction points and misalignments in clinical service delivery and organizational management systems, as well as upgrading revenue cycle management services. We believe that this form of organizational transformation represents a crucial step towards expanding access to behavioral health services to help address the mental health crisis in America.

The speaker, Jeff Huber, a former graduate of the same alma mater, and an entrepreneur who has held distinguished positions at EBay and Google, delivered a speech whose title I have taken the liberty to borrow for this piece. In his address, Mr. Huber implored the young graduates to take their knowledge, skills, motivations and desires to effect real change in the world. He spoke about the mandate to improve society by pursuing innovation. A video and text of his remarks can be found by searching online and are well worth your time.

His message has been churning in my mind since that day, as it has helped me to collect my thoughts about our roles as professionals. Specifically, I speak about the professions with which I am most familiar, psychology and law. However, I believe that this applies more generally, to all of the professions. I share those thoughts with you now.

Innovation in the professions isn’t optional– it’s absolutely crucial. Yet, fostering advancement is exceptionally challenging for many reasons. There is a natural human resistance to change… ask any parent who has raised a child. Perhaps resistance to change is an evolutionary trait designed to maintain the stability of the organism. Or maybe it is simply a tendency to gravitate towards laziness. We all learned in high school physics class the principle that a body in motion tends to stay in motion while a body at rest tends to eat donuts and play video games. Certainly, for us adult humans, there is a definite response cost to altering our behavior since it requires the expenditure of energy, a shift in concentration and attention, a willingness to face unpredictability, and the engagement in new learning activities.

Maintaining the status quo in a profession reflects not only a loss of inertia, but more fatefully, it marks it for death. Just like in nature, a pond without the flow of fresh, running water leads to stagnation. Without an influx of fresh ideas and outside-of-the-box thinking in the profession, our work and the value that we can offer society will morph into something merely passé and inconsequential.

Anyone actually willing to spearhead change, to lead the way to introduce a new idea, method, product, or service must be willing to face resistance, resentment, passive aggressive behaviors, and sometimes even outright active hostility by supporters of the status quo. One must remain resilient in one’s beliefs and drive to foster needed change and innovation. As professionals providing services to the public, this includes improving quality, outcomes, client satisfaction, value-to-cost ratio, and efficiencies, among others.

During my earlier days in business consulting, I recall a tale shared by a motivational speaker. The gentleman related a unique behavior observed by lobster fisherman. He described that lobster traps must remain closed with their lids securely fastened if there are only a couple of lobster inside. However, add a third lobster and a fascinating phenomenon occurs… the lid can be removed without fear of the animals escaping. Why? Because when one of the three tries leaving the enclosure, the other two will pull him back inside, intent that they all stick together and suffer the same consequence. I don’t know if this truly is how lobsters behave, but the message gleaned is a telling one. The escape to freedom is sometimes hindered most by our fellow inmates.

I have had the great fortune of meeting some extraordinarily successful entrepreneurial business leaders and learned from them a mantra to which many subscribed. “To become successful, observe the masses… and then do the opposite!” Resistance and push-back sometimes comes from the places that you would least expect it. It can come from your colleagues or supervisors. It even can come from the so-called “leaders” in your field, individuals who, although held in high regard, are short-sighted, are locked into antiquated ways of thinking (dinosaurs, as my now retired professor friend once called them,) or who lack incentive due to self-interests such as money, power or control.

A good friend of mine, a recently retired executive at an aerospace firm, told me about his experiences as a young engineer when he advocated transforming one of the company’s product lines towards use of what was then this new idea called digital technology. He was shunned and threatened by his colleagues and superiors for upsetting the proverbial apple cart, for daring to suggest that there was a better way ahead. Believing in himself and his mission, he independently developed a modernized version of one of their devices and created an opportunity for the company to sell this new prototype to a customer. After ten years of advocating for and demonstrating the value of upgrading their products, his ideas finally were fully embraced his superiors – ideas that since have become the standard technology now used in his field.

Looking back 30 years in my own psychology career, I often have gravitated towards innovation. This probably is a residual effect of my engineer father constantly tinkering in his garage workshop when I was a child, building strange machines. Like an electronic “eye” that automatically opened our garage door when his car approached (oops, the first version also opened the door for strangers!) or an “electronic slide rule” (think: electronic calculator).

Whether in the area of clinical treatment, forensic assessment, or organizational development, I’ve always believed that since problems continued to exist in every area of my selected profession, and in society at large, opportunities therefore abound to provide solutions. That fix might not always be perfect, or for that matter, even effective. Indeed, some of my ideas have succeeded while others dramatically have not.

Any professional, someone just starting out in a career or someone like me who has been around a while, can adopt an entrepreneurial spirit. It starts with you. To paraphrase Woody Allen, “The key to success is simply showing up!”

Find a small core group of like-minded individuals who also want to change the world for the better. Find key advocates in the field in which you want to introduce reform — persons who support a culture of innovation. Be relentless. Winston Churchill was once famously quoted as saying, “Never, never, never give up!”

Working past the fear of being possibly ostracized is simply a part of the personal growth process, and the energizing spirit of being an entrepreneur and change agent. Expect low points and high points, setbacks and times of elation. It’s all part of that same process.

This is a Call to Action to make a difference in your profession and in the world. It’s about professional evolution and revolution. I encourage you to think about and to heed these suggestions for they will produce for you immeasurable benefits. Not just for you personally or for your profession specifically, but for society at large. On the other hand, dismissing these ideas and negating these opportunities may risk the future relevance and the necessary development of your profession. After all, who wants to become a permanent resident of Jurassic Park?