Evaluation and Treatment of Worker’s Compensation Patients
C.
Donald Williams MD CGP
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Introduction
The aim of this paper is to describe an approach to the treatment of patients
with workplace injuries that includes individual psychotherapy, group psychotherapy, and
pharmacotherapy. The interplay of Axis 2 disorders with depression, anxiety, and pain, and
their implications with regard to prognosis and treatment will be discussed. Our third aim shall be to provide you to with a
brief overview of those systemic and organizational factors that promote health and
prevent disability; those that promote recovery if an injury is sustained; and those which
promote disability and retard recovery.[1]
Background
Workplace injuries exact a huge economic burden in our society. In 1994 compensation costs, treatment costs, and
other indirect costs amounted to $171 billion, including direct costs of $65 billion and
indirect costs of $106 billion[2]. Injuries cost $145 billion and illnesses $26
billion. Low back pain alone was calculated
to cost $26.8 to $56 billion in medical care, compensation payments, and time lost from
work. 90% of these costs are incurred by the
5% who become chronically disabled.[3]
A treatment model similar to that used for soldiers injured in wartime has
been employed for the psychiatric treatment of injured workers. Wartime military practice emphasizes a highly
structured, non-analytic approach with an emphasis on a rapid return to the combat
military unit. In the case of injured workers, the emphasis has been shifted to focus on a
rapid return to work. Underpinning this
approach is wartime experience: soldiers with a post-traumatic stress disorder who were
not returned to their units quickly tended to develop full-blown and disabling chronic
conditions resistant to conventional therapeutic efforts, depriving combat military units
of manpower.
Clinicians and organizations involved in the assessment and treatment of
patients who experience workplace injuries frequently employ this military derived model.
The stated goal is a rapid return to the workplace. Action-oriented
medical interventions and physical therapy, accompanied by admonitions to “learn to
live with the pain” are commonplace.
However, biases on the part of physicians may lead to incomplete evaluations,
missed diagnoses, and treatment failures.[4] [5] The false belief that psychological problems and
psychiatric disorders are the primary cause of chronic pain syndromes may cause doctors
and claims administrators to label patients as neurotic or malingering. In fact, chronic pain more often precedes
depression, and causes social and psychological problems.[6]
Another false belief is that receipt of compensation and retention of a lawyer reduces the
likelihood of RTW.[7] In fact, prospective studies fail to demonstrate
any predictive power regarding future employment status.
A third false belief is that receipt of compensation will prevent a return to work. Both prospective and retrospective studies
contradict this assumption.[8] [9]
The interplay between pre-existing personality disorders and workplace
injuries is complex. Disputes regarding
whether the workplace injury or the preexisting personality disorder is responsible for
maintaining ongoing disability are commonplace. One
side asserts that the personality disorder sustains the disability, while the other
maintains that “but for the injury” the worker would still be working. In one respect, both sides are correct. The process can be more accurately understood as
one in which the fragile sublimatory outlets for aggression are disrupted by the injury,
disrupting the fragile ecology of the individual, disturbing his relationships with
family, friends, coworkers, and society. [10] [11]
Popular notions regarding the prevalence of fraud appear to be inaccurate as
well. Recent statistics published on the
Internet by the responsible state agencies regarding fraudulent claims by workers reveal
incidence rates that are remarkably low.[12] For the two year period 1992-94, of 9000 completed
investigations, there were less than 150 guilty findings, a rate of under two percent (of
actual investigations, not of total claims). Investigation
costs are not low however; using budget figures and case activity data compiled for eight
states, each guilty finding cost $117,000.[13]
These prejudices are not new. In
1893 Freud observed of Charcot, “In the first half of the eighties, …he
succeeded in proving the presence of regularity and law where the inadequate or
half-hearted clinical observations of other people saw only malingering or a puzzling lack of conformity to
rule.” “Let us suppose that a heavy
billet of wood falls on a workman’s shoulder. The
blow knocks him down….After a few weeks, or after some months, he wakes up one
morning and notices that the arm that was subjected to the trauma is hanging down limp and
paralyzed…” Freud then proceeds to
elaborate his theory of psychical trauma, and the hysterical symptoms which result. Prior
to Charcot, hysteria was deemed unworthy of study because it was viewed simply as
malingering.
Both administrative and professional cultures interfere with effective
evaluation and treatment. In the administrative realm unsophisticated or narrow
conceptions regarding cost containment, cost shifting to the social security disability
system or other public agencies, and a need to show cost cutting results for the immediate
reporting period may lead to a denial or delay of treatment and diagnostic authorization. In the medical realm, psychiatric abnormalities
that are the normal response to chronic pain may cause physician withdrawal, disinterest,
and hostility. A lack of familiarity
with alternative treatment models with demonstrated efficacy might result in a failure to
employ the most effective methods. Insurer
behavior may also contribute to poor outcomes; necessary diagnostic studies are often
delayed, or denied. Physicians may choose not to order needed studies because of the
administrative conflict and inconvenience associated with such requests.
This comes at a price. Rehabilitation
by comprehensive multidisciplinary teams yielded a RTW average of 54-85%, depending on
patient selection, compared to less than 30% of chronic patients receiving conventional
treatment.[14] Referral delays for comprehensive treatment for
Back Pain Patients have been shown to increase direct costs[15]
by $15,000 to $50,000.
Complexity must be recognized. “The
first step in making a diagnosis is to think of it. Discarding
discordant data, trying too hard to make a favored diagnosis fit, and refusing to let go
of the assigned diagnoses are all diagnostic traps in which even a seasoned clinician can
tumble.” [16]
Reading an elegant paper on “Clinical Problem Solving” by George E. Thibault,
the reader’s attention is captured by the drama and tension associated with a rapidly
developing medical crisis. That it concludes with the death of the patient because of a
failure in the diagnostic process lends urgency to the principles that it highlights.
Similar crises of conceptualization and problem solving exist in psychiatry,
but they often elude notice. Why? Perhaps it
is in part because the time scale by which we practice is elongated; rarely do we have a
drama like Thibault’s, with a failure to accurately appraise a clinical problem
leading so quickly to a fatal outcome. Our failures occur in slow motion, and are more
easily ignored. It is easier to ignore or
overlook poor outcomes when they occur without fanfare.
A fatalistic attitude that such outcomes are to be expected given such [a
condition] or [that kind of patient] is easier to sustain. Such pseudoexplanations may
prevent clinicians from subjecting the underlying assumptions on which they are based to
appropriate critical scrutiny.
A sense of history is valuable. The
example of hysteria has been cited above, and there are others. Before John Cade and Morgan Schou discovered the
effectiveness of Lithium in the treatment of bipolar mood disorder, manic-depressives were
generally considered untreatable. It was only in 1970 that the FDA approved lithium for
the treatment of mania. Before the work
of Mahler, Winnicott, Masterson, Kohut and others in the mid 1970’s, patients with
Borderline and narcissistic disorders were rarely treated effectively; they simply were
not understood. It was not until 1980 that the persistence of ADD into adulthood was
generally recognized, and that emphasis began to be placed on attentional deficits. Only
in the last ten years has the importance of comorbid disorders and combination therapy
been generally appreciated.[17] Ten years ago no effective treatment was available
for Obsessive Compulsive Disorder.
In each of these examples, progress resulted from advances in neurobiology, a
better understanding of psychological developmental issues, or both. Careful clinical observation and the systematic
testing of hypotheses and the corroboration of findings by independent observers led to
further conceptual refinements of theory and practice, and therefore to more effective
treatment.
My thesis is that injured workers with their psychiatric problems are in the
same boat that their Hysteric, Bipolar. OCD, Borderline, and ADHD predecessors were 5, 15,
25 and 100 years ago; poorly understood by most clinicians today, they often receive
little or no treatment or ineffective treatment when they are referred. Their treatment
failures occur in slow time. There is a
disconcertingly familiar (to psychiatry) tendency to speak and act disparagingly towards
these patients. They are often evaluated and treated by psychiatrists who lack experience
in approaching their complex problems with a biopsychosocial model. And with the decline in psychotherapy
training in most current residency training programs, many new psychiatrists lack the
knowledge and requisite experience dealing with transference and countertransference
phenomena to function effectively with these challenging patients, either in an evaluation
or in a treatment mode. In fact, it especially must be appreciated by clinicians that
countertransference phenomena are powerful influences in the conduct of psychiatric evaluations.
I propose a theoretical approach to treatment
that encompasses an awareness of diagnostic, developmental and psychodynamic issues.
Patients with workplace injuries may develop psychiatric disorders as a
result of the traumatic losses associated with injuries on the job.[18] These conditions include Major Depressive
Disorders, Panic Disorders with or without Agoraphobia, and Pain Disorders. Injuries and the losses that follow in their wake
often bring pre-existing personality disorders to light or aggravate those already in
evidence.
Group psychotherapy [19] is a treatment model that
offers a clinically specific and cost effective response to patients injured in the
workplace. Depressed patients without
comorbid diagnoses can often be treated successfully with group therapy alone in
combination with pharmacotherapy. Candidates
for individual therapy in combination with group therapy include depressed patients with
comorbid diagnoses of Borderline Personality Disorder (or borderline traits), Panic
Disorder with or without Agoraphobia, or a combination of these diagnoses. A solitary emphasis on the immediate return to
work with suppression of all feelings of loss, anger, and grief regarding the trauma of
the injury is more likely than not to yield poor clinical results. A bio-psycho-social approach should be utilized to
take into account the particular circumstances and opportunities presented by patients
with workplace injuries. Injured workers
carry multiple psychiatric diagnoses as a rule, with depression present in nearly all
patients and Axis II conditions present in three fourths of cases referred for treatment. Anxiety, Pain, and substance abuse disorders are
other commonly encountered comorbid conditions requiring specific treatment.
The psychiatric clinician treating injured workers becomes aware
of certain features common to such patients. Mild to Severe Major Depression is present in most, if not all of
those referred for psychiatric evaluation. The
injured worker in this referral population typically develops major depressive symptoms
between eight and fourteen months after the date of the industrial injury. This depression results from a multiplicity of
causes including:
1)
loss of role status, both in the family and in the community;
2)
loss of self-esteem based on the increasingly apparent disparity between the
damaged real self and the internalized pre-injury self-representation;
3)
chronic pain;
4)
loss of hope of recovery;
5)
activation of intrapsychic negative self-representations previously compensated for
through having established a successful work role identity;
6)
an inability to re-establish their fragile early sublimations for the expression of
aggression.
Panic and other anxiety disorders occur more frequently in
injured workers describing abuse and neglect in their developmental histories. However, an intensification of symptoms often
occurs in concert with the social withdrawal that frequently accompanies disabling
injuries. Agoraphobic symptoms in particular
have a tendency to become more prominent.
Pain disorders (when not the
result of missed physical diagnoses) are almost invariably associated with depressive
illness. Patients who have difficulty putting
feelings into words complain more of pain. Patients
who have a highly developed capacity to symbolize affects may experience pain in equal
amounts, but they devote less attention to it and are less preoccupied with pain than
their less-verbal counterparts.
Treatment Modalities—Group Psychotherapy:
Group psychotherapy[20] is a treatment model
that offers a clinically specific and cost effective response to patients injured in the
workplace. The nature and severity of the patient’s psychiatric condition determine
session frequency.
Group psychotherapy can
be effective in enhancing the treatment of personality disordered patients, whatever their
comorbid Axis I diagnoses may be.[21] It allows for the
use of peer pressure and confrontation, with specific and concrete learning opportunities
making the patient aware of the impact his socially dissonant conflicts have on other
members of the group.[22] As Alonso and Rutan
point out, “The patient must internalize and introject new realities, including an
internalization of the current relationships in the current maturational environment. This must occur over and over again in order for
the process of working through to take place. Through
working through, the patient is able to combine insight and internalization and to
transform old character traits to new.” In
a particularly illuminating observation, they comment, “The big difference between
working in a group versus working in a more controlled dyadic environment is that the
group patient is in a position to immediately have
the problems in the group that bedevil his or her life outside their group.” This
leads to a therapeutic and creative interchange among members of the group, which, over
time, facilitates new and healthier introjections and internalizations. This is of major
value in the workplace and in the family.
Group therapy alone,
with appropriate pharmacotherapy for depression, or anxiety disorders, can be particularly
effective with this patient population. Group therapy offers an approach that can
accelerate treatment with a wide spectrum of patients, including those who would be
unlikely to benefit from traditional individual psychotherapy, whether psychodynamic or
cognitive in nature.
“Group therapy is recognized by many
clinicians as offering advantages over individual psychotherapy alone, when used in the
treatment of certain patient populations.
Some medical patients have difficulty in experiencing and expressing their feelings
directly and often express their feelings somatically.
Because of that affective style, those somatasizing patients often have trouble in
establishing a relationship in individual psychotherapy or become regressed and
overdependent on the therapist. Group therapy
is often more effective than individual therapy for somatasizing patients because the
group provides an opportunity for multiple transferences.”[23]
Borderline
patients with life threatening behavior may need to be seen on a daily basis as an
alternative to inpatient hospitalization; this is cost effective and therapeutically
advantageous because of its tendency to be less productive of regression. The group therapy sessions can be increased or
decreased in frequency as the patient’s condition dictates, from one to five times
per week. Since the groups are comprised of different members there is less likelihood of
regressive dependency developing. Continued functioning is required, with the patient
being encouraged to talk through intense feelings rather than act them out.
Once or twice weekly individual therapy sessions may be necessary
to enable some patients to tolerate the group work. This may arise when issues involving
intense shame and embarrassment need to be partially detoxified in an individual setting
prior to being dealt with in the group. For example, an initial revelation of compulsive
self-mutilation is often possible only in an individual setting, because of the
often-overwhelming affect accompanying the behavior and its meaning. It can likewise be
destructive to healthy group functioning if the time and attention needs of one member are
so great that they lead to that person’s monopolizing the group’s time for an
extended period.
Substance abuse coexists frequently with affective, anxiety and
personality disorders.[24] Vigorous multimodality
treatment interventions may be required, including separate inpatient or outpatient
substance abuse treatment and combination pharmacotherapy targeted to the coexisting Axis
I diagnoses. These patients are demanding and
difficult clinical challenges. Patient
non-compliance is a major cause of poor treatment outcome, contributing to their poor
prognosis. Private clinicians might consider referring these high-risk patients to
institutional settings to diminish the likelihood of splitting treatment efforts.
Patients with solitary diagnoses of Major Depression, Pain
Disorder, or these diagnoses in tandem can often be treated effectively with a combination
of group therapy and pharmacotherapy, requiring little or no individual therapy. This
decision should be made on a case by case basis.
Brief Summary of Population and
Results
119 consecutive patients with workplace injuries who are currently
being treated or who have completed psychiatric treatment in a private psychiatric
practice are described. The average age was
46, with a range of 22-64 and a standard deviation of 10 years. 45 (38%) were female and 74 (62%) were male. 16 patients (2 female and 14 male) continued to
actively abuse alcohol or drugs, and were dropped from treatment because of their
unwillingness to enter substance abuse treatment. None
of this group returned to work. Of the
remaining 103 patients, 38 returned to work, 17 continue in a transitional state with a
reasonable likelihood of returning to work, 7 have retired with state pensions because of
the severity of their injuries, 53 failed to return to work, and 4 have unknown outcomes. Return to work is defined as having successfully
completed a meaningful training program, or having returned to work in a capacity that was
meaningful and satisfactory to the patient. The duration of treatment for patients who
have successfully returned to work ranges from 0 months (patients that were working at the
beginning of treatment) to 5 years. Ages of
successful RTW patients ranged from 24 through 61 (mean=41, SD=9). The ages of unsuccessful RTW patients ranged from
28 through 64 (mean=48, SD=10). Unsuccessful RTW patients had a higher frequency of more
severe Axis 2 diagnoses (borderline, schizoid, avoidant and antisocial) and panic disorder
as the primary axis 1 diagnosis in addition to depression.
All patients had attorneys to represent them in their worker’s compensation
claims. Youth, intelligence, higher
educational attainment, an absence of childhood abuse, and higher status jobs were
favorable but not finally determining factors. Even
some apparently unlikely patients successfully returned to work, sometimes with the
assistance of lengthy and intensive group and individual psychotherapy. These statistics, i.e. a 37% RTW rate with an
additional 15% likely to return to work, compare favorably with some published reports of
RTW success rates (20% in one integrated program that treated patients that had been out
of work an average of 4.9 years).[25] Other programs have reported higher return
to work rates, but they have dealt with carefully selected populations, and were comprised
of patients whose time off work has been considerably less. It may be that developing an
flexible and intensive group therapy treatment modality for personality disordered
patients in combination with a meticulous
approach to the pharmacological treatment of comorbid axis 1 disorders contributed to the
successful treatment of some patients. This hypothesis will need to be confirmed by other
clinicians.
Successful treatment does not always mean return to work; either the physical
injuries may be too severe, or the internal resources of the patient may not be
sufficient. Sometimes symptom reduction and suicide prevention represent the limits of
what can be accomplished clinically given currently available treatment strategies. Additional study of the data obtained in this
patient sample may yield more refined approaches to determining prognosis and the most
effective treatment approach, if indeed treatment is indicated. It should also be stated
that future advances in technique and knowledge will yield further improvements in RTW
percentages.
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