Introduction

Psychiatric illness and disability affect individuals’ day-to-day functioning, sometimes in devastating ways. This may include a loss of work capacity, which has been defined as the balance between abilities and work demand (Gold & Shuman 2009), and the ability to integrate into the labour market. van Niekerk et al. (2004, p. 3) have pointed out that ‘numerous barriers at the human, family, organisational and societal levels prevent people with psychiatric disabilities from performing their work roles in accordance with their own needs to participate in work, or not’. Inadequate functional capacity and work capacity are of concern not only for the ill or disabled person and his/her family but also for employers, insurers and attorneys. Occupational therapists’ expertise in assessing residual functional capacity, coupled with their knowledge and skills in relation to activity analysis, allows them to accurately determine the requirements of a particular job, self-care task, home management activity or leisure pursuit and to match these to the individual’s residual abilities and limitations. They can then express considered opinions as to whether or not individuals are likely to meet the relevant task demands. Such opinions are useful for employers (in making decisions regarding the affected employee’s work), insurers (in processing disability claims) and attorneys (in quantifying and resolving compensation claims and civil matters).

Thus, the role of an occupational therapist in the corporate, insurance and medico-legal sectors is chiefly that of an independent, objective expert advisor/consultant/evaluator. There is no therapist–client relationship in the traditional sense, and services are primarily rendered to the referring party (employer, insurer or attorney). Indeed, in many instances, the therapist and client have no further contact after a single evaluation session. The resulting report is typically not given to the client but is instead forwarded directly to the referral agent (from whom the client may request a copy). In medico-legal matters where the case goes to trial, the occupational therapy report may also become a matter of public record.

History of occupational therapy services in the corporate, insurance and medico-legal sectors

Employers and their disability insurers have long called on occupational therapists to assist with the processing and managing of disability claims, which have significant economic consequences for employees, employers and insurers. Indeed, the group life insurance industry in South Africa began employing occupational therapists as claims assessors as long ago as 1991 (Byrne 2003) and has for many years also contracted with occupational therapists to act as evaluators, treating practitioners and case managers in relation to claimants. Medico-legal occupational therapy services in South Africa also began largely in the 1990s, when attorneys began making widespread use of occupational therapists to serve as expert witnesses in matters such as Road Accident Fund (RAF) claims and civil claims (Randall & Crosbie 2004).

Being able to predict return-to-work prospects and evaluate work capacity is crucial in the insurance and corporate fields, where occupational therapists’ main roles are to comment on and intervene in relation to work-related functioning. In the medico-legal field, occupational therapists are asked to express opinions not only on individuals’ work capacity but also on their functional capacity in general, as part of the process of quantifying functional losses and loss of the amenities of life. Kennedy (1997a, p. 2) sums it up as follows:

changes in the law regarding compensation for loss of capacity to perform household services have led to increased demand for occupational therapists’ assessment skills to determine the impact of impairment upon individuals’ abilities to perform unpaid labour such as housekeeping, child care or yard work and the cost of replacing this labour. Judges now require detailed information on functional abilities. Individuals such as entrepreneurs or farm wives, whose work is multi-dimensional, can benefit from the occupational therapist’s ability to analyse and describe their jobs and relate this to their past, present and potential function. It is a positive sign that occasionally both sides in a dispute will agree to share the cost of an occupational therapy assessment and analysis of costs of future care.

Referrals from employers, insurers and attorneys typically rest on a need to answer questions about an individual’s residual abilities and limitations, following an illness, disabling event or incident with functional sequelae. From the perspective of a psychiatric occupational therapist, referrals may derive from the following needs:

• An employer would like to know if an employee who has been off work with a stress-related illness still has sufficient work capacity to perform a particular job.
  
• A company doctor would like to know what reasonable accommodations are needed for an employee recently diagnosed with bipolar affective disorder.
  
• A claims assessor at a disability insurance company would like to know whether a claimant who has been out of the workplace for some time after being diagnosed with schizophrenia has sufficient work capacity to return to his/her usual occupation or move into an alternative occupation.
  
• A risk manager at a disability and absenteeism management consultancy would like to know the current work capacity of an employee with a history of taking excessive sick leave for mental health reasons – this is part of a pre-claims screening or early intervention process, designed to avert inappropriate disability claims.
  
• An attorney would like to know whether a claimant who was in a car accident and has psychiatric and psychological sequelae will manage with his/her day-to-day tasks and whether he/she has any loss of work capacity.
  
• An attorney handling a divorce matter would like to know whether the wife’s long-term depression has affected her work capacity and ability to perform home management and parenting tasks, as this will have a bearing on spousal support and child custody issues.

In all of these instances, occupational therapists may be appointed to provide a properly substantiated and unbiased professional opinion, with no vested interest in the outcome of the matter. The tools of the trade are the evaluation processes, methods and tests utilised to come up with one’s opinion, and the finished product in each case is a written report. Where costs of disability are relevant, as in medico-legal matters, occupational therapists are able to help quantify these over the client’s lifespan. As pointed out by Duncan et al. (2011, p. 62), ‘mental illness, in particular psychotic disorders that are untreated or poorly managed, introduces a range of costs that may fall under the radar of health economists and mental health service providers’. On a very practical level, occupational therapists can help determine the likely costs involved.