Testimony of Leonard N. Matheson, Ph.D.

July 23, 1997
Subcommittee on Social Security
Committee on Ways and Means, House of Representatives
One Hundred Fifth Congress

Barriers Preventing Social Security Disability Recipients
From Returning to Work

Leonard N. Matheson, PhD
Director, Work Performance Laboratory
Section Chief, Occupational Health and Ergonomics
Program in Occupational Therapy, Washington University School of Medicine
St. Louis, Missouri

“The use of a process of functional capacity evaluation to resolve problems with the Social Security Disability program.”

Introduction

In 1970, I began to provide rehabilitation services to a teenager named Paul who came to me as a client with a severe head injury at Rancho Los Amigos Hospital in Downey, California where I worked as a pre-vocational counselor in the Pediatrics unit. Over the next few years, I helped Paul adjust to adolescence and eventually to get a job as a spray painter in a furniture plant. I still hear from Paul occasionally during the Holiday season. Paul is a grandfather, married for the second time, has three children who live with him and his wife in a mortgaged home, and is still employed as a spray painter. He has claimed his occupational birthright as an American, in spite of the fact that he easily qualifies for SSDI based on the severity of his impairments. Paul has a seizure disorder, and hemiplegia that stops him from using his left hand and causes difficulties with standing and walking, swallowing, speech, memory, and reading.

Since I had the opportunity to work with Paul, I have assisted more than 7,000 persons with severe disabilities to attempt to enter the work force, most of whom were SSDI or SSI recipients. Approximately 50% of these people have found dependable employment. For all of them, functional capacity evaluation (FCE) guided their rehabilitation and was key to their success.

We should begin with a definition. FCE is a process of measurement and development which can be used to improve the Social Security Administration’s disability determination process as well as to increase the likelihood that occupationally disabled beneficiaries will return to work. FCE can be used as a model of service to improve the health and function of our citizens so that they can return to work, resume full-fledged participation in the economy, restore dignity to themselves and to their families, and improve the overall financial and emotional health of the nation.

Brief History

Functional capacity evaluation (FCE) is a systematic process of measuring and developing an individual’s ability to perform meaningful tasks on a safe and dependable basis. The scientific underpinnings of FCE stem in large part from the research efforts of industrial and human factors psychologists in World War II and thereafter, supported by federal defense funding. The idea of matching the person to the task was extended from this work to the Rehabilitation community in the 1950s with early centers of excellence at the University of Wisconsin, the University of Arizona, and at rehabilitation centers such as Rancho Los Amigos. In those days, it was assumed that persons with severe disabilities who wanted to work probably could be assisted to work and procedures were developed to achieve such goals. From the first, it was recognized that the evaluation of work capacity was a key to success for persons with severe disabilities. This early experience evolved into formal procedures for evaluating functional capacity as a subset of work capacity and marrying that to work-oriented treatment programs. The use of FCE in Rehabilitation has continued to develop over the intervening years. At its present level, FCE is able to offer assistance to American society to match a wide variety of persons with chronic disabilities to a wide variety of meaningful jobs.

Functional

The term “functional” is intended to connote performance of a purposeful, meaningful, or useful task that has a beginning and an end with a result which can be measured. Several authors have described current models of disablement and the rehabilitation process. The model of Rehabilitation depicted in Figure One describes functional limitations in a transitional role between the individual’s impairment and his or her occupational disability. This key segment of the process of the occupational rehabilitation process is the focus of FCE. It is important to focus on functional limitations because they bridge between impairment which is assessed by medical means and disability which is assessed by non-medical means. This is because occupational disability predicts employability better than does impairment. This may be the single most important defect in the current design of SSDI disability determination; the attempt to predict disability from impairment. In order to manage the issues that limit potential to work, it is necessary to move beyond impairment and functional limitation to address performance on job tasks. The impairment-centered model must not continue to be used for this purpose.

Figure 1. Stage Model of Occupational Rehabilitation.
Stage Issue Addressed Measured by or in terms of ... Measurement Professionals
One Pathology Cells, tissue and bone. All appropriate medical diagnosticians.
Two Medical Impairment Anatomic, physiologic, psychologic system health. All appropriate health care providers.
Three Functional Limitation Actions which support task performance. FCE-trained MDs, OTs, PTs, PhDs.
Four Occupational Disability Worker role consequences of functional limitations. Occupational Therapists, Vocational Evaluators.
Five Vocational Feasibility Acceptability of the evaluee as an employee. Vocational Evaluators, Occupational Therapists.
Six Employability Ability to become employed. Vocational Evaluators, Rehabilitation Counselors
Seven Vocational Handicap Ability to perform a particular job. Occupational Therapists, Ergonomists.
Eight Earning Capacity Earned income over expected worklife. Economists.

This model describes pathology and impairment as factors that, taken within the context of the individual’s environmental and personal resources, are the precursors of functional limitation. If the impairment is sufficiently severe, functional limitations can result. If the functional limitations are sufficiently severe and are pertinent to role tasks, occupational disability will be the result. Occupational disability can be thought of as the summation of the role consequences of functional limitations. Another useful definition of occupational disability is that it is the individual’s uncompensated shortfalls in responding to role demands. Figure Two represents this definition in graphic terms.

Figure Two. Work disability occurs at the interface of functional limitations
and worker role demands. [d]

Work Disability Diagram

Evaluation of disability is based on the measurement of the functional consequences of impairment in tasks which are pertinent to the worker role under consideration. Individuals assume several roles in society, such as spouse, parent, neighbor, worker, team mate or customer. When the emphasis is on determining the presence or degree of work disability, the focus must be on tasks in the worker role within the work environment. The extent and type of the work disability is dependent on the individual’s ability to perform these work-relevant tasks.

Capacity

The term “capacity” connotes the immediate potential of the individual, what the person can possibly do at that point in time. The use of this term is somewhat misleading because it rarely is measured directly unless the individual is highly trained and motivated, such as when an experienced athlete competes. Another term describes what is usually measured: “work tolerance.” This is what the individual will actually tolerate or be able to sustain in a work environment. Work tolerance is measured as the individual’s response to known work demands. Work capacity is less than work tolerance and can be inferred somewhat from evaluation of an individual’s response to exhaustive demands. However, exhaustive demands are inappropriate when the focus of the evaluation is on an impaired worker. In this circumstance, the evaluation may be concerned with the individual’s “maximum dependable ability,” what he or she can do on a regular basis in physical tasks such as lifting and carrying or cognitive tasks such as identifying and organizing. This information allows the identification of occupations in which there are jobs the person may be able to perform, based on the assumption that the demands of these jobs are less than the individual’s maximum dependable ability. If we can, in turn, evaluate a person for a particular job, we can focus on ability to handle that job’s task demands. Knowing the SSDI recipient’s maximum dependable ability places us in the ballpark; assignment to a particular position on the team depends on the recipient’s ability to handle the tasks that are found in that position.

Evaluation Compared with Assessment

Functional capacity evaluation should be distinguished from functional assessment. Although the terms sometimes are used interchangeably and some functional assessment instruments are used in FCE, they describe different processes. Generally, FCE is based on performance measurement while functional assessment is based on expert ratings from observation or on the individual’s self-report. FCE employs structured performance protocols using test equipment or simulated activities to measure functional performance while functional assessment employs structured behavior rating scales to rate observations of the individual made by trained observers or self-perceptions made by the individual. Thus, FCE is much more likely to identify work tasks that can be performed by SSDI recipients. Additionally, FCE is much more likely to identify problems with motivation or less than full effort performance because it actively engages the individual in work tasks that demand physical, psychological, cognitive, and neurobehavioral responses. The record of the individual’s responses to these demands reflects his or her resources expressed within that environment and often will provide the evaluator with ideas about how to support the expression of those resources more fully.

Because functional capacity evaluation involves measurement of the individual’s ability to perform work, it involves the interface between both the person and the job. At this interface are tasks that have complex physical, psychological, cognitive, neurobehavioral, and environmental bases. To evaluate the individual without impairment and achieve a safe and dependable match to job demands is difficult; to do so with a person who has an impairment is more difficult; to do so with many people who have a wide variety of impairments requires a comprehensive multifaceted system. For SSDI recipients, there is often not a job to return to or a job available to allow a focus on certain job demand factors, further broadening the scope of FCE.

Legislative Initiatives

It was proposed in the Rehabilitation and Return to Work Opportunity Act of 1996 (HR 4230), that the assessment of capability for vocational adjustment be undertaken on a broad basis, with mandated assessment of work and educational history, abilities and limitations, and interests and aptitudes. This was well-intended but would have resulted in wasteful application of resources. It would be much better to evaluate the occupational potential of a person with a disability on a progressively constricting basis. This would allow the process to be halted before it consumes too many resources. Such limitations on entry would increase the likelihood that the downstream benefits can be made sufficiently supportive and that success will be a likely consequence of full-effort participation. FCE can provide the information necessary to achieve effective gatekeeping to screen out those who are not likely to benefit in order to improve the opportunities provided to those who can truly benefit.

Context of Practice

The FCE process should have a strong therapeutic orientation and should always have a focus on achieving productivity that enlists the individual’s goals, motivation and attitudes toward success. Key indicators of success in this process include:

  • The ability to maintain a focus on meaningful work goals. Goals such as improvement in fitness, decrease or control of pain, alleviation of depression or other psychological impairment, improved cognition, and many others which will be identified in these types of cases must always be considered secondary to return to meaningful work as the primary goal.
  • The ability to focus on function rather than impairment. The medical impairment aspects of the case should be handled in a way that facilitates maintaining a focus on the development of the recipient’s work behaviors. Many of these people have not benefited from medical care; some of them can be vocational successes in spite of their medical circumstances. This will be most difficult and important with regard to pain control and cognitive control. For the person who is disabled by pain, this approach may greatly increase discomfort on a temporary basis. If this temporary increase is not able to be tolerated without strong medication, it is unlikely that the person will be able to work in a competitive market place. However, appropriate medical support to manage benign disabling pain can be accomplished and should be provided. For the person whose organizational, attentional, or judgmental skills are limited due to cognitive disability, careful matching of job tasks to abilities in a simulated work environment will facilitate adjustment and adaptation of the individual and the environment so that productivity is optimized.
  • The willingness to stick with it. At each step of the evaluation process, the recipient must be expected to “pay the price of admission” to the next step by demonstrating a strong willingness to participate, in spite of his or her circumstances. Less than full effort participation should be cause for suspension or cessation of the return to work program. Conversely, full effort participation which demonstrates a high level of motivation must be reinforced tangibly and recognized as the single most important multiplier of ability.

Step-Wise Service Delivery

FCE is a developmental process in which the experiences of the recipient lead to improvement in performance through learning, adaptation, and changes in the supporting environment. It also can have immediate therapeutic effect based on development of self-efficacy as a consequence of feedback concerning functional abilities which are uncovered or affirmed. Finally, it can greatly improve the likelihood that an SSDI recipient will benefit sufficiently from rehabilitation to achieve a return to work. In order to take advantage of these benefits and to maintain the highest level of cost efficiency and not waste resources, the FCE process for SSDI and SSI recipients should be undertaken in steps. At each step, recipients who do not meet criteria for success should be excused from the program in an ever-constricting funnel that preserves resources so that meaningful rehabilitation benefits are provided to those who choose to and/or have the capacity to persevere.

  • Step One: The evaluation must identify the causes of disablement, through the active involvement of the recipient in a simulated work environment, including the implementation of normal work hours, work rules and procedures. The questions to be addressed at this step center around, “What are the functionally limiting factors which have created this occupational disability?” Issues which identify good candidates for return to work include the degree to which the individual demonstrates a strong work ethic, is safe in the work place, is able to understand the task, and is able to get along with fellow workers and supervisors. Recipients will be excused for problems with safety and interpersonal behavior. Recipients with problems with productivity will be retained and move to Step Two.
  • Step Two: The evaluation must begin to minimize disablement by answering the question: “For the functionally limiting factors, are there rehabilitation services which will be likely to improve ability to work?” This is best addressed within a simulated work environment to provide an appropriate context of treatment. This is the step at which work hardening and work conditioning occur. Issues which identify good candidates for return to work include full-effort performance, the demonstrated ability of the individual to negotiate with disabling factors such as pain, fatigue, and the work’s sensory or cognitive overload within the context of his or her effective use of work aids, modifications and productivity enhancement strategies. Recipients will be excused for inability to work through limitations to improve function, maintain a conditioning regimen, or participate daily. As recipients plateau, they will move to Step Three.
  • Step Three: If the recipient is to enter the work force, we must identify his or her person-centered ability factors. This process should be structured by a work demands taxonomy such as that developed by Fleishman and his colleagues which can be matched to an occupational database in Step Four. This is a broad-based approach to evaluation which will be necessary if the full spectrum of occupationally disabling functional limitations is to be addressed. Using a variety of standardized procedures, the recipient’s aptitudes, abilities, and transferable skills are identified and measured. Issues which identify good candidates for return to work include the identification of resources which can be developed to a level that will be valued by employers, coupled with a positive response to the identification of these resources. Recipients will be excused for levels of aptitudes or abilities which are below a threshold for competitive employment at a level of remuneration that is likely to make the available benefits package unattractive. As a feasible occupational profile is developed, recipients will move to Step Four.
  • Step Four: The collection of work-relevant ability information will provide the recipient with information which will be used in vocational exploration to identify goals, interests, and possible vocational targets if a rehabilitation program were to be undertaken. Issues which identify good candidates for return to work include the identification of occupations which use selected personal resources which can be developed into salable skills, the key to sustainable employment over the next 20 years. This will be based on such services as transferable skill analysis, vocational abilities and interest testing, vocational counseling, and labor market survey to develop and test the match between available jobs and the individual’s potential resources. Recipients who are unable to identify occupations which have jobs in their geographic area which will provide adequate remuneration will be excused. After an acceptable occupational target is identified, recipients will move to Step Five.
  • Step Five: Finally, the evaluation will conclude with rehabilitation plan development. If the recipient has progressed successfully through each of the earlier steps, he or she will be an excellent candidate for a return to work rehabilitation program focused on a particular vocational target, the likely outcome of which will be sustainable employment.

The hallmarks of the FCE process described above are that it is driven by continuing demonstration of the recipient’s effort and is guided by objective information about his or her work performance. These are the keys to return to work for a person with a chronic disability. The consequence of this process should be a recipient who is ready to begin a focused rehabilitation program that often will involve services such as occupational therapy, rehabilitation counseling, and both formal education and on the job vocational training. These are services that should only be undertaken if objective data have been used to develop information about the person with disabilities that makes it likely that he or she will benefit and that the outcome will be sustainable employment.

Policy Recommendations

Standardization: FCE is practiced by professionals from many different disciplines, none of which can lay sole claim. As a consequence, FCE is not formally governed and lacks consistency, resulting in less efficient use of resources and less than optimal outcome for service recipients. The field needs cross-disciplinary standards of practice.

Science and Technology: In the past 20 years, FCE technology has outstripped its scientific underpinnings, resulting in problems with the utility of many of the FCE applications that are in use today. It is necessary to adhere to standards for technology development, including both test protocols and equipment, such as those first published by the EEOC in 1978 which guide employee selection procedures, the American Physical Therapy Association guidelines, and those published by the American Psychological Association which currently are under revision.

Cost Efficiency: An FCE only has utility to the degree it assists in the resolution of a problem and adheres to the evaluation factors hierarchy. To maximize cost effect, data which relate to the likelihood of return to work should be collected using procedures which maintain a reasonable balance among safety, reliability, validity and practicality after developing a sharp focus on the question, “To what purpose will the information be put?”

Summary

The successful return to work of SSDI recipients is a cause for celebration because it benefits all Americans in both tangible and spiritual ways. These people have the need and many have been found to be amenable to rehabilitation. The General Accounting Office has estimated that if only 73,000 of the 6.6 million Americans who receive SSDI and SSI benefits were to return to work, $3 billion could be saved in subsequent years. FCE is an important component of an effective return to work strategy that can be implemented on a national basis. The costs of not making the attempt have become unbearable. Responsible and innovative leadership is required.

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Acknowledgements:

Special thanks to Carolyn Baum, PhD, OTR/C, FAOTA, and Mark Dakos, MS, CVE, for their thoughtful and valuable comments and suggestions that were incorporated into this work.