With Clamor About the President, How Does Forensic Psychiatry Assess Fitness for Duty, Anyway?
Numerous political opponents have denounced the President as mentally unfit for duty, drawing from the opinion of a number of psychiatrists who have openly drawn the medical specialty into the discussion. But what does a fitness for duty evaluation (FFDE) actually entail? Psychology Today’s Katherine Schreiber recently interviewed Dr. Michael Welner to learn more about how a forensic professional must go about informing these questions with forensic and scientific integrity in mind.
Katherine Schreiber: What does an FFDE consist of and how do FFDE components vary by profession?
Dr. Welner: A proper FFDE gathers history of workplace incidents leading one’s fitness to be questioned. In my experience, incidents outside of the workplace are not used as a basis for FFDE unless they involve drug abuse or hospital admissions that herald a major psychiatric condition. Workplace incidents may reflect a behavioral deterioration, or unresolved conflict with a co-worker or supervisor. Sometimes incidents are misunderstandings, but those misunderstandings sort themselves out before one is referred for psychiatric attention. Other instances involve fake incidents that are developed to create a paper trail to get a rival displaced, a longstanding employee laid off or pushed to early retirement, or to justify firing.
The professional FFDE focuses first on establishing a valid ground truth of what happened in the workplace incident, because without ground truth of what is happening at the workplace, an opinion is useless or has the risk of being dishonest and aiming at a particular result. Without access to records from the workplace, and individuals to interview at length who are part of that workplace and witness to the goings on, there is no such thing as a valid FFDE.
Once there is a clear understanding of an incident(s), the examiner must learn what were the triggers and causes. This is where interviews of close friends and family who witness one’s day to day behavior in private, and those witness to the private goings on at work, are most informative. Diagnostic testing can be helpful but may be too non-specific. Diagnostic testing without ample history to give it context is also meaningless and potentially misleading.
Once an examiner has a ground truth for what actually happened in the incident(s) triggering an FFDE request, understands the causes, contexts, and events leading up (the back story), one then aims to resolve the nature of the risks for these incidents to continue, present in another fashion, worsen, or occur with worse consequences. This is the risk assessment portion of the FFDE. Some psychological tests can provide general data to inform FFDE and risks of future incidents, but they are no substitute for available history about causes and the likelihood that the causes will recur.
Schreiber: Which professions are we most likely to see FFDEs requested in, even if they are not mandated?
Dr. Welner: FFDEs may be requested in professions in which people interact with the public on a regular basis, particularly when safety issues may be part of those interactions. Anyone involved in patient care, be they a doctor, nurse, or physician’s assistant, may be referred for a FFDE in the course of concerns about one’s behavior or function. Law enforcement professionals are typically referred after violent confrontations with members of the public. Drivers and engineers of public transportation have enormous responsibilities and hold risk to public safety, and may be referred based on a low threshold for sorting out one’s fitness for duty. Those in the military likewise can present great risk. Other professions that draw great investment in an individual, such as NFL athletes who may be drafted and highly salaried, are tested with such mental fitness in mind.
Schreiber: What is the value of screening new hires responsible for public safety (e.g., law enforcement, firemen) for their fitness for duty? Why are such exams needed?
Dr. Welner: Because one cannot undo a reversible tragedy, and those who are armed have to make decisions under pressure that are irreversible judgment calls.
Schreiber: When are FFDEs appropriate? When are they inappropriate?
Dr. Welner: FFDEs are appropriate in issues that cover public or workplace safety or the orderly conducting of business operations every day. They are not appropriate as a means of a person being marginalized or sidelined by those colleagues who are enemies or who belong to different factions. Politics exists in the workplace as it does anywhere else and politics is necessary to extract and exclude from a valid and reliable FFDE.
Schreiber: How reliable and valid are FFDEs?
Dr. Welner: FFDEs are more valid and reliable only if they are based on ground truth of history and incidents. As for conclusions based on that data, some professionals may reasonably disagree on how to interpret certain data. In my experience, the most common reasons for experts to disagree are 1) one relied upon much more qualitative and/or quantitative data and is better informed, and 2) that one (or both) were biased and looking to cater to the agenda of one side.
Schreiber: What measures assessing mental "fitness" (or stability) are used in FFDEs?
Dr. Welner: There are many psychological tests. However, there are only a few that self-regulate against an examinee trying to make a particular impression. The MMPI-2 and PAI are personality tests that can discern whether a person is providing an invalid response style. When valid, they can inform diagnostic questions raised by history about the severity of illness, or one’s personality style.
However, no psychological testing measure fits into the exact responsibilities one has, the expectations of what a person does day to day, the nature of how that person interacts with others, and their ability to competently address their responsibilities. A person can have even significant pathology on psychological tests and yet be quite fit for duty. Or, pristine psychological tests and total lack of fitness for duty. History resolves and reconciles this question. An ounce of fact is worth a pound of expertise, and an ounce of fact is worth a pound of the best testing.
Schreiber: What can they tell us about people that can't otherwise be observed?
Dr. Welner: What risk reflects is risk under certain circumstances. Risk under circumstances of battle, or conflict, or surprise, for example. These are not what one observes in an interview or even under conditions of routine testing.
Schreiber: What are the consequences for the employer and employee of having an FFDE performed?
Dr. Welner: When an FFDE is ordered, it can be embarrassing to the employee in question. The FFDE arises typically for someone who has little insight into the need to get help independent of the workplace getting involved. Those with greater insight, seek out help from a doctor or counselor BEFORE their employer or workplace gets involved. Thus the person who is referred to an FFDE commonly feels nothing is wrong and finds the process itself humiliating and to be forced on them.
When the FFDE arises out of a workplace dispute, it demonstrates to the affected employee that the workplace or the referring EAP is taking the other side – whether that is fair or not. The employee often complies reluctantly as a condition of maintaining employment.
As for the employer, there are few consequences unless the referral for an FFDE is done in bad faith. That can be difficult to tease out because the same scheming that forces a person into a bogus FFDE controls other employees into going along with the plan to discredit a particular employee.
Schreiber: Do the results remain on an employee's medical record?
Dr. Welner: FFDE are done outside one’s typical treatment apparatus, in order to have one evaluated by an unaffiliated doctor. They are arranged by one’s workplace, and so they may, depending on the employer, remain part of an employment record rather than a medical record.
Schreiber: In terms of military individuals who get screened and evaluated prior to placement, do those who carry the nuclear football get any kind of special screening over and above what standard military recruits get? What about military officers?
Dr. Welner: I cannot say what provisions are in place. Pertinent to your considerations of the presidency, a criminal record that a person accepted money for political favors disqualifies one from a security clearance, including the clearance necessary for that level of classification.
Schreiber: Does assuming power in some way affect judgments that might be related to public safety?
Dr. Welner: Of course it does. David Dinkins lost the mayoralty of New York by allowing rioters to “vent” in Crown Heights, New York. Ferguson, Missouri was destroyed because those in power used poor judgment and allowed lawlessness and onsite national news media instigation of rioting, without forceful protection of public safety. The emerging catastrophic scandal emerging from the highest echelons of the Department of Justice and the Obama administration centers around how many Americans were spied upon and information used to harm them in a variety of ways, to be detailed in a forthcoming release from the House Intelligence Committee.
Power affects judgments that relate to public safety. And psychological screening, under the circumstances, protects the public far less than does the willingness of those in power to apply the rule of law to prevent others from abusing power.