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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.”

 
Psychological Evaluations in Litigation: A Practical Guide for Attorneys and Insurance Adjusters is available as a free e-book.

Newsletters
 
 
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.

 

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

 
 
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.

 
Ultimately, the decision is based on my subjective estimate after considering the objective data
 
 
HARRIS: Do you follow a different process when analyzing causation of permanent disability, or “apportionment”?

LECKART: No.

   
 
 
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.
 
Developmental events are over-rated with regard to apportionment.
 
 
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.
   
 
 
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.

 
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.
 
 
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.

   
 
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.

   
 
 
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


 
For a detailed CV, click here.