1. Resolving Psychological Barriers to Vocational Rehabilitation
Brad L. Bates, PhD
Tacoma Psychology, PLLC

2. Resolving Psychological Barriers to Vocational Rehabilitation
A rehabilitation psychologist can provide the following services to help you resolve psychological barriers:
Psychological testing for learning disabilities
Diagnosis of and psychotherapy for mental health disorders
Psychosocial assessment and intervention for physical health conditions

3. Psychological Testing to Resolve Barriers
Learning Disability Testing

4. Psychological Testing for Learning Disabilities
What are the Testing Codes?
Psychological test evaluation ( ) and test administration ( ) codes
Neuropsychological test evaluation ( ) and test administration ( )

5. Psychological Testing for Learning Disabilities
When Refer for Psychological Testing?
History suggests possible learning disability
Vocational testing finds low aptitudes
IW is failing classes in current retraining program
Pre-existing learning problems may combine with the work-related disability such that IW is eligible for the second injury fund

6. Psychological Testing for Learning Disabilities
When Refer for Neuropsychological Testing?
History suggests a possible brain injury that might negatively affect brain functioning
Any of the following is important:
Determining causal connection between brain injury and the industrial injury
Course and prognosis of the brain injury
Treatment recommendations for the brain injury

7. Psychological Testing for Learning Disabilities
A Sample Learning Disability Test Battery
Intelligence
Wechsler Adult Intelligence Scale, 4th edition
Memory
Wechsler Memory Scale, 4th edition
Rey Auditory Verbal Learning Test
Academic Skills
Woodcock-Johnson Tests of Achievement, 4th edition
Performance Validity

8. Psychological Testing for Learning Disabilities
Intelligence
Wechsler Adult Intelligence Scale, 4th edition
Verbal Comprehension Index
Perceptual Reasoning Index
Working Memory Index
Processing Speed Index

9. Psychological Testing for Learning Disabilities
Memory
Wechsler Memory Scale, 4th edition
Immediate & Delayed
Auditory & Visual
Rey Auditory Verbal Learning Test
Trials I – V, Trial B, Trial VI, Delayed Recall

10. Psychological Testing for Learning Disabilities
Academic Skills
Woodcock-Johnson Tests of Achievement, 4th edition
Basic Reading Skills
Reading Fluency
Reading Comprehension
Basic Writing Skills
Math Calculation Skills
Math Problem Solving

11. Psychological Testing for Learning Disabilities
Performance Validity
Not named to protect validity
Assess effort and motivation during testing
Rigorously researched to stand up in court
Provide objective data in cases of suspected malingering

12. Psychological Testing for Learning Disabilities
What to Expect From a Learning Disability Report
Review of relevant records
Thorough history
Clear presentation of test data
Concise summary of test findings
Diagnosis with relation to industrial injury
Occasional diagnosis of malingering
Guidance re: accommodation and remediation of deficits
Discussion of vocational implications

13. Psychological Testing for Learning Disabilities
Possible Diagnoses
Specific Learning Disorder, reading (F81.0)
Specific Learning Disorder, mathematics (F81.2)
Specific Learning Disorder, writing (F81.81)
Borderline Intellectual Functioning (R41.83)
Malingering (Z76.5)

14. Psychological Testing for Learning Disabilities
Possible Accommodations
Use of a calculator to help with arithmetic calculation
Permission to audiotape lectures
Help with notetaking during lectures (i.e., a scribe)
Help developing, organizing, writing & editing written work
Use of word processing equipment for editing and spelling
Individually proctored tests with transcription by the proctor
Grade on content and meaning, not basic writing skills.
Audiotaped textbooks
Extra time on tests

15. Psychological Testing for Learning Disabilities
Example Guidance re: Remediation
Research indicates that adults (typically 16 – 30 years of age) who receive research-based and systematic reading instruction from a well-trained teacher, ideally four times a week for one and a half to two hours per session, can expect to increase their reading one grade level for every one hundred or so hours of instruction. Keeping in mind that Henry is 55 years of age and would likely learn more slowly than this, it is reasonable to believe that with proper instruction, he could increase his current reading level to 9th grade level in roughly two years.

16. Psychological Testing for Learning Disabilities
Example Discussions of Vocational Implications
If I were to translate Henry’s current cognitive and academic test results into GED levels (1 – 6 with higher scores representing stronger abilities), I would suggest the following:
Reasoning – 3, Mathematical – 2, Language – 2
If I were to translate Henry’s current test results into GATB aptitudes (1 – 5, with 1 representing the top 10% and 5 the lowest 10%), I would estimate the following:
G – 3, V – 4, N – 4, S – 2, P – 3

17. Psychological Testing for Learning Disabilities
Example Discussions of Vocational Implications
Research indicates that individuals with borderline intellectual functioning and a specific learning disability are capable of employment but that the large majority work in entry level service positions and benefit most from on-the-job training or job coaching (rather than community college or vocational-technical school).

18. Psychological Treatment to Resolve Barriers
Mental Health Codes vs.
Health & Behavior Codes

19. Mental Health Codes What are Mental Health CPT Codes?
Codes for both diagnostic evaluation ( ) and treatment ( )
Diagnose mental health disorders according to DSM- 5 (e.g., Major Depression, PTSD, Adjustment Disorder)
Treat mental health disorders using cognitive, behavioral, social, or psychophysiological interventions
Key idea: focus is on assessing and treating mental health

20. Health & Behavior Codes
What are H&B CPT Codes?
Codes for both assessment ( ) and intervention ( )
Allow billing insurance for treating patients with a medical condition but not a mental health disorder
Improve physical health using cognitive, behavioral, social, or psychophysiological interventions
Promote adherence to medical treatment
Symptom management (pain)
Encourage healthy behaviors (exercise, diet)
Reduce unhealthy behaviors (smoking)
Improve adjustment to physical illness or disability
Key idea: focus is on improving physical health

21. Mental Health Codes
Examples of How Mental Health Treatment can Resolve Barriers
Psychotropic medicine to address psychosis or bipolar disorder
Cognitive therapy to stabilize major depression
Acceptance therapy to work through an adjustment disorder
Prolonged exposure to reduce PTSD symptoms
Assertion training to reduce negative interpersonal interactions resulting from a personality disorder

22. Health & Behavior Codes
Examples of how Psychosocial Intervention can Resolve Barriers
Education regarding chronic pain to boost participation in OT/PT
Cognitive therapy to promote exercise and diet changes
Smoking cessation pre- and post-surgery
Pain management to assist with tapering opioids

23. Mental Health vs. H&B Codes
Additional Considerations re: Mental Health and H&B Codes
Mental health codes require preauthorization; H&B codes do not
Mental health treatment is likely to last 3 – 6 months; treatment via H&B codes is likely to last 2 – 3 months
Reimbursement for mental health codes is roughly 33% more than for H&B codes

24. Mental Health vs. H&B Codes
Additional Considerations re: Mental Health and H&B Codes
Using H&B codes, a mental health disorder cannot become attached to a claim
The diagnostic evaluation with mental health codes is more comprehensive than the psychosocial assessment with H&B codes
If uncertain, I recommend you refer using mental health codes and let your rehabilitation psychologist use his/her expertise to determine whether a mental health disorder exists and requires treatment

25. Mental Health and H&B Codes
What to Expect From Mental Health Treatment & Psychosocial Intervention
A treatment plan that targets the specific issues that are barriers to rehabilitation
Objective assessment of progress
Typed notes that are general enough to protect highly-personal information but specific enough to convey the focus of the session and techniques used
Time-limited
Available for phone or consultations

26. Tina the Truck Driver
55 y/o, 10th grade education, likely learning disability, neck & LB pain, restricted to light work, eligible for retraining
Angry, depressed, scared, rarely leaves home. Misses appointments, not pleasant when attends, very resistant to vocational rehabilitation.
Consider a mental health evaluation as there is reason to suspect a mental health disorder (MDD vs Adj DO vs Personality DO)

27. Tina the Truck Driver Major Depressive Disorder Weeks 1 – 8
Medication referral
Stabilize mood (cognitive therapy)
Begin pain management (mindfulness meditation)
Learning disability testing
Weeks 9 – 12
Continue pain management
Begin building a new life (acceptance therapy)
Support vocational rehabilitation
Review progress: discharge or request extension

28. Larry the Laborer
48 y/o, 12th grade education, LB and knee pain, just found eligible for retraining
Seems emotionally stable but mental status is impaired, likely due to opioids. MD would like to taper pain meds but Larry is reluctant due to pain.
Consider a psychosocial assessment (H&B codes) as there is no apparent mental health disorder but pain management may assist with opioid taper

29. Larry the Laborer Opioid Taper Sessions 1 – 4 Sessions 5 – 7
Contact MD re: taper plan
Education re: opioids and the taper plan
Begin pain management (mindfulness meditation)
Sessions 5 – 7
Continue pain management
Relapse prevention

30. Nancy the Nurse
32 y/o, RN, right index finger amputated following assault by WSH patient, recently RTW but left partway through first day back
Reports nightmares several nights prior to RTW and a panic attack within hours of walking back onto her ward. Now depressed and afraid to leave home. Feels unable to RTW due to intense anxiety and fear of reinjury.
Consider a mental health evaluation as there is reason to suspect a mental health disorder (PTSD)

31. Nancy the Nurse PTSD Weeks 1 – 4 Weeks 5 – 12 Medication referral
Teach self-regulation (grounding, meditation)
Stabilize mood (cognitive therapy)
Gather additional trauma history
Weeks 5 – 12
Continue self-regulation
Continue stabilizing mood
Prolonged exposure for non-WSH situations
Review progress: discharge or request extension

32. Nancy the Nurse PTSD Weeks 13 – 16 Weeks 17 – 20 Weeks 12 – 24
Prolonged exposure for WSH situations
Contact VRC re: RTW options
Address additional trauma
Weeks 17 – 20
RTW in modified duty (limited patient contact)
Support transition back to WSH
Weeks 12 – 24
RTW in JOI (no restrictions)
Support transition back to JOI

33. Mike the Mason
37 y/o, 12th grade education, shoulder pain, overweight, sedentary lifestyle, restricted to light work, attending Pierce College’s Project Management program
Always friendly, mood seems good, but missing classes due to frequent pain flares. MD recently referred Mike for additional OT/PT. Mike resistant because prior OT/PT didn’t help.
Consider a psychosocial assessment (H&B codes) as there is no apparent mental health disorder but education regarding chronic pain may promote active engagement in OT/PT

34. Mike the Mason Exercise and Dietary Changes Sessions 1 – 3
Contact OT/PT and establish feedback loop
Education re: chronic pain and exercise
Encourage home exercise plan
Sessions 4 – 7
Exchange info with OT/PT re: progress
Education re: chronic pain and diet
Encourage new dietary plan

35. Neuropsychologist Joins Tacoma Psychology, PLLC
John Ernst, PhD, ABPP

36. 1987 – 2019: St. Joseph Medical Center, Neurosciences
2001-2: President, PNW Neuropsychological Society
1994: ABPP, Clinical Neuropsychology
1985-7: Fellowship, Univ. Queensland
1983-4: Fellowship, Univ. Washington
1983: PhD, Univ. Montana
John Ernst, PhD, ABPP

37. Tacoma Psychology, PLLC
Brad Bates, PhD
Geoffrey Soleck, PhD
John Ernst, PhD, ABPP
2102 N 30th St, Tacoma, WA
(fax)