“COMBINED
THERAPY” AS A PRIMARY TREATMENT MODALITY IN THE TREATMENT
OF INJURED WORKERS copyright 1996 Background:
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 all
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 approach. The goal is a rapid
return to the workplace. Action-oriented
medical interventions, physical therapy, and admonitions to “learn to live with the
pain” are commonplace. This posture is based on several considerations, including
cost containment, a belief that protracted time off work may be associated with
prolongation of disability, and the absence of alternative treatment models with
demonstrated efficacy. Current literature indicates that concerns about malingering have
been exaggerated, although it is important for clinicians to remain alert to its possible
presence. “When there
is financial gain from having pain, the possibility of malingering is often paramount;
however, concerns about this are overstated. Patients may exaggerate symptoms and the
extent of disability in order to attain secondary gains, but these usually arise after the
presence of the illness that initiated the pain is established. Actual falsification of
pain and injury appears to be infrequent. The Commission on the Evaluation of Pain (Social
Security Administration 1987) found that malingering was not a significant problem in the
Social Security Administration's disability system. Leavitt and Sweet (1986) similarly
found malingering to be rare in individuals complaining of low back pain. Studies have both supported and rejected the
detrimental effects of litigation and involvement in worker's compensation systems on
chronic pain. In their review, Osterweis et al. (1987) noted that the only consistent
finding among these patients was that those who were employed at the outset of treatment
appeared to do better.”[3] One recent publication[4]
takes exception to a quick fix approach and advocates psychoanalytically oriented
psychotherapy for many psychiatric disorders that occur in the workplace. Although the
focus of attention is on the psychotherapeutic treatment of management personnel rather
than production workers, it explicitly recognizes the important contribution of
developmental and psychodynamic factors in determining the patient’s clinical course
and defining optimal treatment. This represents the beginning of a shift away from the
military derived treatment model for patients with traumatic injuries. Theory:
I propose that fundamental differences between injured soldiers and injured workers
have been overlooked, and that treatment models appropriate for wounded servicemen during
wartime are too broadly applied to workers injured in the line of their duty.
In fact, current policy in the military takes far more account of the need for
rehabilitation of military personnel in peacetime than do policies routinely applied in
the civilian workforce.[5]
The peacetime military stresses the importance of preventing injury and disability;
officers are accountable for the health of their men.
When an injury occurs, every effort is made to restore lost function as quickly as
possible. By contrast, low status workers in
the civilian workforce such as CNA’s in nursing homes are often considered expendable
by their employers, with little effort directed towards prevention of injury or
rehabilitation.
These overlooked differences constitute a principal reason for the failure of the
model to yield more positive results in treating workplace injured patients. Let us consider the differences: 1) Wounded
servicemen in wartime typically suffer anticipated
trauma as a result of combat; injured workers more typically suffer unexpected injury for which they are not
psychologically prepared. 2) Wounded soldiers
tend to be under thirty years of age, and are usually free of prior trauma or disability. Injured workers cover a much broader spectrum both
in age and prior physical and psychiatric condition.
While it is uncommon to encounter a soldier wounded in late middle age, the
opposite is true for injured workers.
3) Wounded soldiers
between the ages of 18-24, in combat situations, are less established with regard to
family and career, particularly in circumstances of major wartime conflict. This younger
population has not yet begun to pursue a career, has yet to develop a defined role within
their community, and they have not developed a clear concept of identity[6].
Civilian workers with on the job injuries, by contrast have often worked for one or more
decades at their current position, have strong ties to the community in which they live,
and have family responsibilities to spouses and children. Because of their age, their
sense of identity is more firmly established. 4) Injured soldiers
come to psychiatric attention and receive medical and psychiatric care immediately after
their injury through military medical facilities; this treatment may continue after their
discharge through the VA system if they require continuing care. Many injured workers are
referred for psychiatric treatment and evaluation with inconsistent frequency subsequent
to their workplace trauma. 5) In wartime the
goal is for soldiers to return to the front line and to be able to function for a period
of several months to a year. With injured worker recovery must be durable over the long
term if it is to be useful to the worker and to society. 6) Injury and
disability sustained in war is honorable and acceptable.
Statues, cemeteries, and medical institutions (the Veteran’s Administration)
have been established to honor and care for soldiers. Such is not the case for injured
workers.
These
differences between wartime soldiers and workers mandate that there be different
approaches to evaluation and treatment within these two groups. These distinctions also
suggest that different treatment goals are appropriate.
Injured workers actually more closely resemble workers threatened with job loss and
employment uncertainty.[7]
Of course, the injured worker also bears the additional burden of physical disability and
pain. Treatment
Considerations:
I propose a theoretical approach that encompasses an awareness of developmental
issues and psychodynamics while treating these patients.
“Combined therapy," defined as a combination of individual and group
psychotherapy[8] is treatment model
that offers the prospect of a more clinically specific and cost effective response to
patients injured in the workplace.
Candidates for combined therapy include depressed with comorbid diagnoses of
Borderline Personality Disorder (or borderline traits), Panic Disorder with or without
Agoraphobia, or a combination of these diagnoses. Such patients usually present with
complex intrapsychic issues as well as pharmacotherapeutic management issues which require
individual attention in addition to group therapy, which is both complementary and
essential. Depressed patients without comorbid
diagnoses can often be treated successfully with group therapy alone in combination with
pharmacotherapy.
Session frequency is determined by the severity of the patient’s psychiatric
condition. 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 little 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 allow for the exploration of dyadic issues in preparation for addressing them in
the group setting. Substance abuse coexists frequently with
affective, anxiety, and personality disorders.[9] 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 an
academic institution, which may be less vulnerable to patient psychopathy by virtue of its
size and impersonality. 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. Internal
Dynamics:
The psychiatric clinician treating injured workers becomes aware of certain
features held in common by such patients who either are referred for or seek psychiatric
treatment. Mild to Severe Major Depression is present in most, if not all such patients
referred for psychiatric evaluation. The
injured worker in this referral population first 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) a 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. Population Description:
In a series of 60 consecutive predominantly blue collar workers’ compensation
patients referred to a private psychiatric practice, Anxiety Disorders were diagnosed in
24, or 39% of these patients. Of these, (10) 16% were diagnosed as having a Panic
Disorder, (9) 15% Generalized Anxiety disorder, and (11) 18% Post Traumatic Stress
Disorder. Four of these eleven patients were felt to have PTSD that was unrelated to their
injury.
Major Depression or Dysthymia was present in (56) 91% of these patients in this
series. Sometimes these two diagnoses coexisted termed “double depression.”[10]
(The DSM-IV states, “In addition, after the initial 2 years of Dysthymic Disorder,
there may be superimposed episodes of Major Depressive Disorder.”)[11]
Somatoform Pain Disorder (termed Pain Disorder Associated with both Psychological
Factors and a General Medical Condition under DSM-IV) was diagnosed in (16) 26% of
patients. This condition is understood as an
outgrowth of depression and injury, often occurring in patients who have worked hard from
an early age with less opportunity to “be a child," and with little or no
opportunity to symbolize feelings by expressing them verbally. This represents a failure
to achieve a developmental level which allows for a more reflective and less action
oriented mode of expression.
Injured workers had co-existing Axis II diagnoses in (50) 81% of all patients
referred for psychiatric care. By far the most common diagnosis was Personality Disorder,
NOS. Fewer than 10% of patients were
diagnosed as having specific personality disorders. The patients with Antisocial
Personality Disorders posed the greatest therapeutic challenge and had the worst outcome. Independent Medical Evaluations often refer to the
presence of Axis II conditions when presenting an argument that a disability is caused by
a pre-existing condition rather than being causally related to or even aggravated by the
industrial injury. In many instances this may
be true, but the complex interplay between personality and response to trauma makes it
difficult to distinguish to what degree a patient’s post injury psychiatric condition
is altered as a consequence of the injury versus the personality disorder. Disputes
sometimes arise between clinicians regarding this question of proximate causality versus
aggravation. Adversarial dynamics among professionals may often be magnified because of
the fact that such evaluations have economic liability consequences attached to them, and
the fact that such evaluations are typically conducted within a legally prescribed
framework, emphasizing the forensic elements of the process.[12]
Multiple psychiatric diagnoses (termed “comorbidity”), were the rule; all but 3 patients in this series
carried two or more diagnoses. This is consistent with recent literature.[13]
The clinician should be alert to the possibility of substance abuse being the primary
disorder, because of its powerful association with antisocial personality disorders
(16.9-29.5%), anxiety disorders (13.2-25.4%), and affective disorders (70.7-85.4%).[14]
Bi-polar disorder alone is diagnosed in more than 10% of opioid addicts.[15]
Group psychotherapy can be effective in enhancing the treatment of personality
disordered patients, whatever their comorbid Axis I diagnoses may be. 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.[16] This is of major value in
the workplace and in the family. A combination of
individual and group psychotherapy, or in some instances, 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.”[17] The injured worker with little formal
education often employs a concrete cognitive style that is well suited to a treatment
structure that brings him into contact with other similarly endowed individuals. The social and educational disparity between the
therapist and the patient is de-emphasized in the group setting, enhancing its credibility
to an often skeptical patient population that is frequently mistrustful of doctors. Clinical Example
(group only): A group of 8 men
with industrial injuries met two times per week. None of them had regularly scheduled
individual therapy sessions, although they had the option of scheduling such appointments
whenever they felt a need. Most group members
asked for private sessions once every two months or so.
The average education was 8th grade, but the average self reported math and reading
level was closer to 5th or 6th grade. All
group members had worked in low paying jobs, earning between $5.00 and $9.00 per hour. None had graduated from high school. Six of the eight had been arrested for alcohol or
drug related matters, or for DWI’s or other traffic offenses. In spite of these problems, all seemed to have a
generally positive working relationship with their therapist. Group sessions
sometimes began with covertly hostile, envious “joking” ambivalent comments
about the difference between their situation and the therapist’s; a common remark
centered on fantasies about cars or boats the therapist might own, or vacations to far
away places. This invited some good natured repartee, which acknowledged the difference in
social class between the group members and the therapist.
Usually, after such comments, some cohesive statement was offered. This sometimes came as a statement by a group
member that he would be “six feet under” if he had not received psychiatric
treatment, or an expressed wish that treatment had been obtained earlier, so that their
problems would not have become so severe. Although this could be interpreted as defending
against feared retaliation, the tone was more one of acknowledging the caretaking aspect
of the relationship, and the benefits that had been realized. Clinical Example (group only): In a group of 7
male injured workers, Jose began to speak of his intense feelings of loss as the
anniversary of the death of his sister approached. He
spoke of visiting the cemetery, bringing her flowers, and asking her why she was gone.
(She was killed in an alcohol related traffic accident.)
While Jose was speaking, George, who was sitting by the window of the group room,
began to make comments about the short-skirted women outside a department store across the
street. His irrelevant comments seemed to
irritate the other group members, but nobody said anything.
Jose fell silent, and stared at his feet. George
seemed to be inviting an appreciative response from other group members about his
“macho” comments, but nobody said anything. The therapist commented on the fact
of George’s interruption, and wondered out loud if any of the other group members had
any thoughts or feelings about it. Bill said
that he had felt the same way when George had interrupted him in a previous group session. Jose said that he was angry about being
interrupted, and felt that George was not interested in what he felt or said. The therapist commented that one of the ground
rules of group therapy was that whoever was talking be allowed to finish what they were
saying without interruption. George appeared
surprised by the reactions of the other group members. He seemed defensive, and apologized
without a sense of sincerity. The therapist commented that perhaps there was something
that made George uncomfortable when other people expressed intense feelings; maybe he felt
uncomfortable with his own intense feelings. He
did not know whether or not this was true, but would think about it. George had been made
aware of his interrupting behavior and thoughtlessness and the effect it had on other
members of his group. George subsequently admitted to continuing alcohol and substance
abuse and dropped out of treatment. Jose
completed therapy and returned to work on a full time basis. Clinical example
(combined therapy): Marge was a woman
in her mid thirties, married to her second husband for eight years. Her family history included a mother with whom she
never experienced closeness, and who ultimately abandoned the family, never contributing
to its support although she attended school continuously and ultimately obtained a
graduate degree. Her father was an abusive
alcoholic salesman, who maintained only sporadic contact subsequent to her adolescence. She described a
troubled adolescence. In her 20’s she
was hospitalized for psychiatric treatment following suicide attempts on several
occasions. Counseling and psychiatric
treatment occurred over several years, and were beneficial but not curative. Her back injury
occurred while employed in a management position in a mall based fast food outlet. She
presented a history of relatively continuous adult employment and continuing education. Her first marriage
ended in divorce; her husband obtained custody of the children, although he proceeded to
have relationships with 23 women. The
children moved to live with her in their early teens following her marriage to her second
husband. They had serious behavior problems, ultimately coming into contact with the
criminal justice system. She was referred
for treatment two years following her back injury, diagnosed as two ruptured disks. Two psychiatrists diagnosed her as having a Major
Depression, severe. She later stated that she had previously received a diagnosis of
Borderline Personality Disorder in her late teens. Although
some borderline traits were still in evidence, she no longer qualified for the diagnosis
at the time of referral; she was diagnosed as having a Personality Disorder, NOS. Nine months after
beginning treatment she had demonstrated little benefit from aggressive pharmacotherapy,
individual psychotherapy, and group therapy, initially at a frequency of two times per
week but later increased to four times per week. A
handgun was confiscated when it was learned that she was planning suicide. The individual and group psychotherapy sessions
were characterized by periods of silence, sarcasm, and anger alternating with other
periods of some wit and humor along with some capacity for self reflection and
psychological work. When hypomanic
symptoms became apparent 18 months into treatment, the history was reviewed in greater
detail, and the diagnosis was revised to Bipolar Mood Disorder, Most recent episode mixed. Therapeutic work continued in an intensive manner,
with pharmacotherapy efforts directed toward mood stabilization. When this ultimately proved to be unsuccessful,
she was referred for a course of unipolar ECT which produced a marked improvement in mood.
Following a relapse a course of bipolar ECT was initiated; however, this led to the reactivation of a previously dormant
panic disorder, and she withdrew consent for her ECT. She maintained some of her gains,
but her bitter hopelessness surfaced frequently. The decision to conduct combined therapy was a consequence of the observation that she would often not participate in group alone, withdrawing into a shell that was difficult to penetrate. In twice weekly individual sessions she tended to be more open when encouraged, giving voice to feelings of despair, cynicism and rage. She described experiences of neglect and abuse she felt nobody (her parents and siblings) wanted to hear. She was usually mistrustful and angry at the therapist, who experienced the sessions as difficult and frustrating (leading to an examination of countertransference phenomena in consultation). Later in treatment she became able to participate more openly in group sessions, which she continued to attend three times per week. She was able to both identify and empathize with other group members confronting similar internal and external problems, and began to feel less isolated. The group consisted of a mixture of patients with and without workplace injuries. They were relatively verbal, and had all demonstrated some capacity for psychological work and insight. She began to talk more openly in her groups about wishing at times that she were dead, and about how she had written poems to be given to her (unappreciative) children posthumously. Earlier in treatment she had tended to delay reports of near suicide experiences (reckless driving, etc.) until days or weeks after the occurrence. This movement to more contemporaneous expression of “dangerous” feelings represented progress. She continued to utilize the twice weekly individual sessions to give voice to frightening feelings of murderous rage too threatening to express in group. Often the individual sessions appeared to be the warm-up for subsequent expression of similar issues in group. Treatment continues, and appears to be one or two years from completion. Clinical Example (combined therapy): Ms. T. is a 40
year old divorced person who lives with her 18 year old daughter. She recently separated from a significant other
with whom she had lived for five years. Ms. T. maintained
steady employment, often working at two jobs simultaneously. She sustained a shoulder and
neck injury while working at a restaurant as a bar manager. Ultimately, she was forced to
seek specialty treatment, and consulted with
two orthopedic surgeons. The initial surgery
was not successful. When told by her surgeon
that she was unlikely to improve, she became seriously depressed. Until then she had hoped
that her efforts at rehabilitation would yield a clinical improvement. A second surgery was performed six months later
but was not helpful. Some months later
she sought psychiatric treatment at her new employer’s recommendation. She was diagnosed with a Major Depression, Single
Episode, Severe. The developmental history
revealed that Ms. T. is the oldest of 4 children. Her mother worked as a cook full time,
while her father worked in highway construction. Responsibility
for the care of the younger children fell to her. Her
mother was neglectful and narcissistic, devoting her time to work and
“partying,” much to Ms. T.’s growing resentment. She described one episode at age 6 or 7 when she
sustained a fracture falling off a swing set, but was not taken to the doctor for 5 days. This history of negligent care by her parents
created major problems with trust, and later became important in her relationship with
physicians. She was an honors
student in high school, and was offered several scholarships to colleges and universities,
but without any interest or support from her parents, she chose instead to marry at 17. Her spouse proved to be alcoholic, physically abusive, and did not work steadily; the
marriage ended in divorce after 7 years when she decided, “I could take care of
myself and my daughter better without him.” She
worked in lounges, becoming a lounge manager at a chain seafood restaurant, the position
she held when she was injured. Although other factors were recognized as contributory, Ms.
T.’s depression was determined to be causally related to her injury. She presented with no prior history of clinical
depression. No formal Axis II diagnosis was
rendered at that time, although Personality Disorder NOS with dependent and histrionic
traits was diagnosed later. Treatment with
antidepressant medication and psychotherapy was recommended. After a four month delay, individual psychotherapy
was approved. Group psychotherapy at a frequency of two times per week was instituted
shortly thereafter. The two groups were differently constituted; one group was comprised
of high functioning employed professionals, while the other group consisted of a more
diverse set of people, half of whom had workplace injuries, but with a lower overall
average level of functioning. In her first experience with the second group she was
exposed to an intense expression of transferential rage (although not directed at her
personally) which was frightening; although a partial resolution and working through was
accomplished, even after the departure of the group member in question it was never fully
possible for her to connect with the group. Ultimately
she decided to drop her participation in this group.
The second group was intimidating in a different manner—all the group members
were highly successful, and she felt inadequate by comparison. With continued participation over a two year
period, she came to feel more a part of the group, and transferential responses were
easier to analyze. Internalization of the ego
strength demonstrated by other group members was therapeutically important to her
development. The patient's
employer contacted me, with permission, and stated that her job performance had
deteriorated to the point where it would no longer be possible for her to continue. Specifically, she mentioned impairments in memory
and concentration. Numerous
antidepressant medications were given a trial, and outside consultation was obtained
regarding the pharmacotherapy. Side effects were a major problem for Ms. T., but she did
derive some benefit from a combination of antidepressant agents. Individual therapy
sessions were substantially devoted to sorting out her medication difficulties. A psychiatric IME
was performed that strongly criticized the individual and group therapy she received, and
offered the opinion that Ms. T. would never return to work as long as she was involved in
psychotherapy. Ms. T. experienced this
evaluation and interview process as a setback and responded with both anger and some
questioning of her treatment. This provided the opportunity to work through some
transferential rage in both her individual and group therapy. A mutual decision to decrease group session
frequency to one time per week was made, based on a negative therapeutic response to
members of the particular group. Treatment
continued, at the rate of one time per week individual and group psychotherapy. The patient investigated the possibility, with
some encouragement from her therapist, of working as a paralegal for attorneys on a
contract basis, utilizing skills and knowledge she already possessed. Although afraid of “another failure” she
proceeded to investigate this possibility, with the help of her vocational counselor. She began working as a contract paralegal for an
attorney. Currently she is
working in this capacity approximately 15-30 hours per week. Treatment issues that have arisen and been
analyzed in both her individual and group treatment relate to identification with the
workers whose files she reviews. She has
stated that continued treatment is necessary for her to “keep my head clear.” She plans to continue group psychotherapy on an
indefinite basis, paying for it privately, if necessary, following closure of her claim.
Her individual therapy will be tapered. Discussion:
As these cases illustrate, the approach to
evaluation and assessment of an injured worker should take into account the premorbid
psychiatric status, the developmental history, and the course of the post injury
condition. A solitary emphasis on 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.
The social aspect of group therapy can
make it less frustrating and more therapeutically gratifying, particularly in the early
phases of treatment. The group approach also
has a lesser tendency to foster dependency on the therapist. Patients new to group treatment learn from the
“old hands” who have progressed. The
first hand exposure to successful treatment completion of other patients brings realistic
hope to those patients new to the treatment process.
Specific knowledge regarding pharmacological treatment, including side effects, is
also beneficial. It often is more meaningful
to a patient to hear another group member describe his experience with a medication than
to hear only what the doctor has to say. Compliance
is enhanced, since patients have an opportunity to see first hand how discrete individual
medication response patterns can be.
The value of talking through feelings is learned more quickly in an open ended
group, since there are always “older” group members describing how they have
benefited from the process. As group members
progress, they can sometimes be transferred with therapeutic benefit to another group that
functions on a higher cognitive level. These
transitions are made gradually, allowing for substantial overlapping of group
participation.
More seriously disturbed patients often require more intensive treatment, involving
several group and individual sessions each week. Since
other groups have different membership, there is less tendency to become dependent on
specific individuals, and instead to focus more upon talking in groups. This facilitates progression from acting out of
feelings and thoughts to their symbolic representation, with modulation, transmutation,
and working through. Summary:
The evaluation and treatment of patients with workplace injuries is a complex task,
requiring sophisticated and complete evaluation and diagnosis.[18] Although an excellent literature exists to provide
guidance regarding the evaluation process, less has been written regarding treatment.
The application of treatment models, developed in a military setting, to injured
workers has often been disappointing. Important
differences between the two populations have been overlooked, including age, family and
career status, and the extent of identity formation.
Treatment approaches which respect these factors are more likely to yield positive
results than approaches that emphasize suppression and denial. The psychiatric treatment
of injured workers must be guided by an awareness of the presenting Axis I and Axis II
diagnoses, and current knowledge regarding their treatment, in order to obtain the best
results.
This paper proposes that psychotherapy that incorporates both individual and group
psychotherapy along with appropriate pharmacotherapy offers advantages for selected
patients as compared with traditional treatment approaches usually employed with this
patient group. I describe these advantages with clinical examples.
These patients 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. Acknowledgment The assistance and
encouragement of Charles Mangham, M. D. in the preparation and development of this paper
is gratefully acknowledged. [1]
Grant, B.L. and Robbins, D.B., ”Disability,
Workers Compensation, and Fitness for Duty,” Mental
Health in the Workplace: A Practical Psychiatric Guide, Kahn, J.P. ed., Van Nostrand
Reinhold , New York, 1993. [2]
Williams, C. D., “New Approaches to Diagnosis in Disabled Patients,” American Psychiatric Association, Annual Meeting.
Miami, 1995. [3]
King, S. A., and Strain, J. J., “Pain Disorders,”
Treatments of Psychiatric Disorders, 2nd Edition, Gabbard, G. O. (Ed.),
American Psychiatric Press(American Psychiatric Electronic Library}, Washington, D. C.,
1995. [4]
Kahn, J.P. and Unterberg, M.P, ”Executive Distress: Organizational
Consequences,” pp. 106-129, Mental Health in the Workplace :A Practical
Psychiatric Guide, Kahn, J.P. ed., , Van Nostrand Reinhold, New York, 1993. [5]
Personal communication, Chris Flynn, M. D., Chief of Psychiatry, Tampa Veteran’s
Administration Hospital. [6]
Colarusso, Calvin M.D. “Time Sense in
Young Adulthood,” The Psychoanalytic Study of
the Child, pp. 125-144, Yale University
Press, New Haven and London, 1991. [7]
Kates, N., et. al., ”Job Loss and Employment Uncertainty,” pp. 156-176, Mental Health in the Workplace: A Practical
Psychiatric Guide, Kahn, J. ed., Van Nostrand Reinhold, New York, 1993. [8]
Porter, Kenneth M.D. “Combined Individual and Group Psychotherapy,” pp. 314-324, Comprehensive Group Psychotherapy, Kaplan and
Sadock, eds., Third Ed., Baltimore,
Williams and Wilkins, 1993. [9]
Jaffe, J. H., “Opioid-Related Disorders” p. 843, Comprehensive Textbook of Psychiatry, Kaplan and
Sadock, eds., Sixth Ed., Baltimore, Williams and Wilkins, 1995. [10]
Keller M. B., Shapiro R. W., ``Double depression'': Superimposition of Acute Depressive
Episodes on Chronic Depressive Disorders. Am J Psychiatry 139: pp. 438-442, 1982. [11]
Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, p. 346, Washington, D. C., American Psychiatric
Association, 1994. [12]
Rosenberg, J. E. and Eth, S., “Ethics in Psychiatry,” p. 2773, in Kaplan, H. I.
and Sadock, B. J., (eds.) Comprehensive Textbook of
Psychiatry, Sixth Edition, Baltimore, Williams and Wilkins, 1995. [13]Oldham,
J. M., et. al., “Comorbidity of Axis I and Axis II Disorders,” Am J Psychiatry
152:4, pp. 571-578, 1995. [14]
Rounsaville, B.J., et. al., “Heterogeneity of Psychiatric Diagnosis in Treated Opiate
Addicts,” Arch Gen Psychiatry, 39: 162, 1982. [15]
Ibid. [16]
Azima, F. “Group Psychotherapy with Personality Disorders,” pp. 393-406, Comprehensive Group Psychotherapy, Kaplan and
Sadock, eds., Third Ed., Baltimore, Williams and Wilkins, 1993. [17] Ulman, Kathleen H.
”Group Psychotherapy with the Medically Ill,” pp. 459-470, Comprehensive Group Psychotherapy, Kaplan and
Sadock, eds., Third Ed., Baltimore, Williams and Wilkins, 1993. [18] Williams, C. D., “Evaluation and Treatment of Disability: Individual and Organizational Levels,” Work, Stress, and Health ‘95: Creating Healthier Workplaces. American Psychological Association, Washington D. C., 1995.
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