An integrated approach to return to work with mental injuries or illnessMasterclass

Tuesday 15 October 2019

WELCOMEWELCOME

• Welcome to the masterclass

• Overview of today

• The other important stuff you need to know

MEET YOUR PRESENTERS

Matthew Bannan

Matthew is a registered physiotherapist and is the

executive lead of the Professional Services

customer group segment which incorporates the health

and community care, education and Government

industry sectors.

MEET YOUR PRESENTERS

Jayne Crawley

Jayne Crawley is a registered psychologist with over with

nearly 20 years’ clinical experience including trauma

based services with first responder agencies, EAP, services and occupational

rehabilitation.

MEET YOUR PRESENTERS

Dr Quentin Mungomery

Dr Quentin Mungomery is a Consultant Psychiatrist with over 20 years’ experience in

clinical, forensic and occupational psychiatry.

MENTALLY HEALTHY WORKPLACESPromote: strategies to promote positive mental health practices

Prevent: systematic safety management practices to address psychosocial hazards

Intervene early: strategies to manage stress and address psychological injury and harm to worker healthSupport recovery: following psychological and physical injury/illness

CASE STUDY

MEET JASMINE

• Jasmine is a 40 year old registered nurse who works in the Emergency Department (ED) at a large tertiary hospital in Brisbane

• She has specialised as an ED nurse for the last twelve years; having previously worked in general medical and surgical wards.

• Jasmine is married and has two children, aged 8 and 10 years.• Jasmine works full time on a rotating shift pattern• More recently Jasmine has had some personal and family issues which

have intermittently impacted on her attendance at work• Her colleagues have noticed that she often appears tired at work and can

be snappy at times which is unusual for Jasmine

CASE STUDY

EARLY INTERVENTION

• Accessing personal leave – absenteeism or late in attending work• Presenteeism – inability to stay focused, lowered level of

concentration and impaired memory• Withdrawal from staff and not participating in team meetings or

social events at work/ non communicative• Snappy and irritable mood• Lack of sleep

WHAT ARE THE SIGNS?

• Performance issues• Other health or personal issues• Interpersonal conflict with colleagues or supervisor• Requests for flexible work arrangements• Shift and roster requests denied• Recent complaints against individual• No ongoing leave balance

WHAT ELSE?

• If the person asks for help, support them to access• If the person talks/hints of thoughts of suicide• If the person is abusing alcohol and/or other drugs to deal with the trauma• Enduring or increasing reactions (after 4 weeks)

- Ongoing distress- Social withdrawal- Recurring, intrusive thoughts of the incident

• Decline in functioning (after 4 weeks)- Work performance (operational errors, impaired concentration)- Avoidance

WHEN DO YOU SEEK PROFESSIONAL HELP

MORE ABOUT JASMINE

• Jasmine is at work on an evening shift on a Saturday night• Jasmine and her colleagues are asked to commence triage on an male patient

who was brought in by paramedics after being collected from the Brunswick St Mall

• The patient is quite agitated, confused and appears to be under the influence of alcohol and/or drugs

• The patient lashes out violently and assaults Jasmine, physically hitting her in the face whilst screaming abuse at her and others

• The patient is restrained by security officers• Jasmine is attended to by her colleagues for minor soft tissue injuries to her

mouth and face

CASE STUDY – PART TWO

IMMEDIATE ACTION

“Research shows that workers who receive treatment, care and support as quickly as possible after the injury are more likely to return to meaningful work.”

Psychological First Aid

• Psychological First Aid seeks to reduce the distress and attend to basic needs following a potentially traumatic event.

• This does not need to be administered by a psychologist and a suitable person in the workplace can undertake the one-day training course. It provides comfort, information, support and practical assistance.

• The primary goal is to enhance a person’s natural resilience and coping capacity.

IMMEDIATE ACTION POST-EVENT

WHAT TO DOIF AN INJURY OCCURS

• Get the necessary medical assistance immediately

• Lodge a claim with WorkCover or your insurer

• Support your worker and stay in contact throughout their recovery

Lodge onlineworksafe.qld.gov.au

Call 1300 362 128

Lodge through your treating doctor

• Jasmine was not rostered to work for the next 4 days• Jasmine attends her GP three days after the event at work and is

issued with a workers capacity certificate• She is certified totally incapacitated for work for two weeks with a

diagnosis of soft tissue injuries to her face and mouth and PTSD• Her GP refers Jasmine for counselling sessions with a psychologist

and prescribes Valium to help her sleep• Jasmine lodges an Application for Compensation with WorkCover

Queensland

CASE STUDY – PART THREE

APPROACHING THE CLAIM

• We utilise an approach framework but we consider each situation individually and tailor our approach for every injured person

• A flexible approach to determining and managing mental injury claims

• What is best for each individual claimant and employer?• How can we help?• Limiting the possible negative effects of seeking compensation

Remember that the person has still suffered an injury

OUR APPROACH

• “Reject” , “should be rejected” and “disputed”• Providing an unqualified medical opinion• Case law references or “chapter and verse”• Legal terms and phrases• Accusative language• Hearsay and unsupported information• Applying RMA to specific non-RMA events

WORDS AND BEHAVIOURS TO AVOID

• Unfiltered responses i.e. dumped HR policies; HR records and other correspondence

• Mixing up or merging HR/IR and workers compensation issues• No communication with your workers – this includes managers and

supervisors• No focus on RTW or stay at work• Follow your own policies and procedures• Timeliness in everything you do – investigations, communications,

making SD available

WORDS AND BEHAVIOURS TO AVOID

MENTAL INJURIES AND ILLNESSES

Most common causes of work-related psychological injuries

• Work overload/pressure 31%• Work-related bullying and harassment 27%• Exposure to workplace occupational violence 14%• Exposure to a traumatic event• Motor vehicle accident• Being assaulted• Sexual/racial harassment• Secondary to work-related physical injury

What are the most at risk occupations ?

• Defense Force members, firefighters and police

• Automobile, bus and rail drivers

• Health and welfare support workers

• Prison and security officers

• Social and welfare professionals

Most common work-related psychological injuries

• Adjustment Disorder with mixed anxiety and depressed mood

• Posttraumatic Stress Disorder

Adjustment Disorder

• Development of emotional or behavioural symptoms in response to an identifiable stressor/s

• Within three months of the onset of the stressor/s

• Symptoms are clinically significant and cause marked distress and associated impairment in social and occupational functioning

• Once the stressor/s has ceased the symptoms do not persist for more than six months.

Posttraumatic Stress Disorder

• Posttraumatic Stress Disorder is a particular set of reactions that can develop in people who have been through a traumatic event

• That is, they have experienced or witnessed an event which threatened their life or safety, or that of others around them

• And led to feelings of intense fear helplessness or horror (DSM-IV)

Types of traumatic events

• This can be• a car or other serious accident• physical or sexual assault• war or torture• disasters such as bushfires or floods.

• Other life changing situations such as being retrenched, getting divorced orthe expected death of an ill family member are very distressing and may causemental health problems, but are not events that can cause PTSD.

Signs and symptoms

• Reliving the traumatic event

• Avoiding reminders of the event

• Negative alterations in cognitions and mood

• Being overly alert or wound up

Reliving the traumatic event

• Intrusive and recurring distressing memories/vivid images

• Distressing dreams or nightmares with content or affect related to the trauma event

• Dissociative reactions (flashbacks - where it feels like the event is recurring)

• Intense emotional or physical reactions when exposed to triggers or reminders• sweating• heart palpitation• or panic when reminded of the event.

Avoiding reminders of the event

• Deliberately avoiding • activities • places• people• thoughts or feelings

• Associated with the event because they bring back painful memories.

Negative alterations in cognitions and mood

• Inability to remember important aspects of the traumatic event – dissociative amnesia

• Persistent and exaggerated negative beliefs, thoughts or expectations about oneself or others – guilt, mistrust, catastrophic thinking

• Feeling cut off and detached from friends and family

• Persistent negative emotional state-fear, horror, anger, guilt or shame

• Markedly diminished interest or participation in significant activities

• Feelings of detachment or estrangement from others

• Persistent inability to experience positive emotions-happiness, satisfaction loving feelings

Being overly alert or wound up

• Sleeping difficulties

• Irritability and angry outbursts

• Recklessness or self-destructive behaviour

• Problems with concentration

• Becoming easily startled

• Constantly being on the lookout for signs of danger-hypervigilance.

TREATMENT

• This will assist in preventing the development of co-morbid conditions including substance/alcohol abuse; depression; relationship issues; suicidality; depression; agoraphobia: OCD and schizophrenia.

• The earlier the exposure to the trauma event the better the outcome for recovery.

• The avoidance of facing the trauma is one of the predominant reasons why some people don’t recover.

Early intervention is the key to recovery

APPROACH TO TREATMENT BEST PRACTICE

Suggested treatment steps for PTSD

• Confirm diagnosis of PTSD by qualified mental health professional• clinical psychologist or psychiatrist (TDR or IME)

• Are there important comorbid problems (depression, anxiety, substance misuse, pain)• seek expert advice regarding treatment sequencing

• Are there significant risks of self-harm, violence or aggression• consider if inpatient care/additional specialist care as required

Suggested treatment steps for PTSD

• Is the worker willing/able to engage in trauma focused psychological therapy• 8 to 12 sessions trauma focused CBT or EMDR

• Have the worker’s symptoms responded sufficiently • review diagnosis/case formulation• further 8 to 12 sessions of TFCBT or EMDR• consider trial of SSRI antidepressant

• Has the worker’s symptoms responded sufficiently after 12-week trial of an adequate dose of medication• if no - review diagnosis and consider additional specialist advice/treatment• if yes - continue medication for at least 12 months

Suggested treatment steps for Adjustment Disorder

• Is the worker willing/able to engage in psychological therapy• 6 to 12 sessions CBT

• Have the worker’s symptoms responded sufficiently • review diagnosis/case formulation• further 6 to 12 sessions of CBT• consider trial of SSRI antidepressant

• Has the worker’s symptoms responded sufficiently after 12-week trial of an adequate dose of medication• if no - review diagnosis and consider additional specialist advice/treatment• if yes - continue medication for at least 6 months

• Earlier than later following a diagnosis – can assist in the prevention of co-morbid conditions

• Most Australians do not receive treatment for PTSD and those who do, do not receive evidenced based treatment.

• Follow guidelines for the treatment of Acute Stress Disorder and Posttraumatic Stress Disorder developed by the Centre for Posttraumatic Mental Health and endorsed by:• The Australian Psychological Society• The Royal Australian and New Zealand College of Psychiatrists• The Royal Australian College of General Practitioners

PTSD TREATMENT – PSYCHOLOGICAL RECOVERY

• Two recommended treatments that are recommended by involve exposure• Eye Movement Desensitization Reprocessing therapy• Trauma - Focussed Cognitive Therapy

• Recovery – holistic approach in the planning stages of treatment with goals established early.

• Social integration and vocational rehabilitation need to be incorporated in the treatment planning phase and include activities either supporting a maintenance of work or RTW as soon as practical. View return to work as part of the recovery not as the end point of recovery

• Strong empirical evidence that psychosocial rehabilitation interventions promote functionality and recovery.

PTSD TREATMENT – PSYCHOLOGICAL RECOVERY

• Treatment involves exposure and reduced arousal through cognitive and behavioural strategies.

• Most effective treatment is Cognitive Behavioural Therapy (CBT) which incorporates changing unhelpful ways of thinking, feeling and behaving. It challenges old and new beliefs and uses practical self-help strategies. It also encompasses some exposure therapy using arousal reducing strategies and challenging negative irrational thoughts.

• CBT can be helpful for individuals who are returning to work to assist them with gaining insight into their thinking regarding the workplace and manage any anxiety that may be occur when return to a workplace.

ADJUSTMENT DISORDER TREATMENT – PSYCHOLOGICAL RECOVERY

• It is ten days after the event at work• Jasmine’s claim has been accepted by WorkCover• Jasmine has commenced treatment with her psychologist• She is progressing but is still not back at work

CASE STUDY – PART THREE

RECOVERY AND RETURN TO WORK

“Injured workers gain confidence by attending a safe workplace that helps them improve their self esteem and mental wellbeing”

HEALTH BENEFITS OF GOOD WORK

The longer someone remains off work, the less likely they will ever return.

70% chance of ever returning20

days off

50% chance of ever returning 45

days off

35% chance of ever returning70

days off

THE RETURN TO WORK ECOSYSTEM

What about returning to work? • Occupational recovery should be considered from the beginning of treatment.

• While time away from operational duties may be required, consider the possibility of adjusted duties/graduated return to work to promote recovery and reduce risk of long-term sickness absence.

• Work-focused exposure therapy may be of additional benefit.

• A period of alternate duties may be required because direct re-exposure to particular events may be overly distressing.

• Workers may be able to safely return to operational duties once their symptoms have improved, even while still undertaking treatment (including medication).

• It should be agreed how their symptom levels will be monitored and what type of symptom recurrence should prompt a re-assessment.

• Return to work should commence at the time of the incident.• Commence a return to work early even if it is just having coffee with the

employee or invite the employee in for work colleague’s birthday celebrations, retirement or team meetings. It is important for social interaction and to ensure that the employee does not experience a sense of isolation. - engagement is key!

• Communication with treating professionals - ask the question…..treatment! Use case conferences

• There are no separate entities in this arena, collaboration for the employee is vital for a return to functioning

• Plan out suitable duties…consult with the treating professionals to what they would recommend and how you can help facilitate their recovery. Focus on the employee's recovery not just when they will return

STARTING RETURN TO WORK

• Be flexible• Employees are individual and no two people are the same or experience

the traumatic event in the same way and will not travel the same recovery journey

• Check with the treating professionals how the employee is functioning and if changes are needed to support the employee

• Everyone is individual, when approaching an employee, be empathic, ask what you can do for them, ask how they would like to be supported. Ask how they would like to be approached

• Research has indicated that manager’s behaviour is a key predictor of mental health outcomes and therefore the success of a return to work program

STARTING RETURN TO WORK

DURING RECOVERY

• Offer return to work options - light or alternative duties

• Get input from the worker, their doctor and other treating practitioners

• Keep talking to the worker about their progress

PLAN FOR THEIR RETURN

• Graduated return to work• Focus on what they CAN do• Aim for sustainable return to work

Use resources at worksafe.qld.gov.au to help you plan their return to work.

WHEN THEY RETURN

• Welcome them back• Supportive culture• Monitor adjustments• Tailor their program • Review regularly

Use resources at worksafe.qld.gov.au to help you support your worker.

TALKING TO PROVIDERS

• Always have the employee’s overall wellbeing as the central focus

• Case conferences are important as it conveys transparency in the process from all sides.

• Ask about improvements in social and overall functioning.• Ask for strategies should their patient/client not be coping at the

workplace• Avoid labels, particularly with PTSD as this can be used as a

barrier to a RTW, rather name it is distress or discomfort

TALKING TO PROVIDERS

• Watch out for the negative alterations in cognitions as the employee may lose faith in the organisation or be safe in the workplace.

• Clarify any misperceptions regarding the workplace.• Do not be defensive, understand that the employee has

experienced an event that has impacted on their functioning.• Reassure treaters that you are flexible and will provide support

for the employee to return to work.

• “How best can I support her in her recovery?”• “What do you believe is her capacity to perform their work role?”• “Is there any additional information we might need to better support her in the

workplace?”• “Can we help with organising any workplace catch-ups before they are ready to

return?”• “Can we organise regular case conferences, either in person or via

zoom/skype?”

REAL CONVERSATIONS WITH PROVIDERS

• “How best can I support you in your recovery?”• “I understand that at times you don’t feel like talking over the phone, but I’d like

to encourage you to use these times as an opportunity to discuss any additional support you may need, and also to help you to feel connected whilst you’re recovering from your injury”.

• “I can hear that you’re becoming frustrated – I understand that these conversations can be difficult. My role is to support you in your recovery at work, but in turn I do need to ask that you speak to me in a calm and respectful manner”

• “I understand that the levels of discomfort you have make it difficult for you to do that at the moment”.

• “What would you be doing differently if the feelings of discomfort you’re having were no longer there?”

REAL CONVERSATIONS WITH INJURED EMPLOYEES

• Breakdown in communication between employee, workplace and return to work coordinator/claim owner

• Limited response to appropriate psychological/psychiatric management including medication or non-compliance

• Inconsistency between the intensity and frequency of psychological psychiatric management and apparent severity of the psychological injury

• Excessive advocacy by treaters on behalf of the employee• Difficulties engaging worker in return to work activities despite apparent

improvement in psychosocial functioning and other areas of life• Industrial issues• Personality disorders• Lawyer involvement• Employee’s manager has an inability to empathise – low support or care• Return to work as an afterthought

FLAGS THAT ALL IS NOT RIGHT

KEY TIPS

Dr Mungomery’s Top 10 claims management tips

1. Be aware that injured worker’s often feel quite overwhelmed and helpless in the initial stages of a work-related psychological injury claim

2. Be mindful of benefits of early positive engagement with injured worker regarding their claim and coordinated return to work planning involving all parties (injured worker, workplace, treating health practitioners, insurer)

3. Maintain an active listening, supportive approach balanced against goal directed activities

4. Establish proactive consistent communication with all parties involved in the claim (injured worker, workplace, health practitioners, insurer)

5. Provide oversight of care to clarify if injured worker is getting adequate and appropriate evidence-based biopsychosocial treatment

Dr Mungomery’s Top 10 claims management tips

6. Be mindful of potential for unconscious bias affecting interactions with the injured worker

7. Be aware of the injured worker’s emotional reaction to you (as well as other parties) and your own emotional reaction to the injured worker

8. Attempt to maintain an impartial balanced approach in interactions with the various parties involved rather than focusing on a specific outcome to the claim.

9. Assist with basic problem-solving regarding claim but avoid ‘slipping into’ a therapeutic relationship with injured worker

10. Maintain a focus on the mental health benefits of successful work rehabilitation for the injured worker

JAYNE’ S TOP 11 CLAIMS MANAGEMENT TIPS

1. Don’t pathologise: don’t label the condition, refer to condition as distress

or discomfort

2. Return to work is part of recovery, look at early engagement with

workplace e.g. Coffee or events

3. Get involved early and suggest suitable/modified duties

4. Ask questions of treaters in regard to treatment and how the workplace

can assist

5. Remember every person is an individual

JAYNE’ S TOP 11 CLAIMS MANAGEMENT TIPS

6. Ask the person how they would like to be managed/approached

7. Don’t be defensive, an injury has occurred.

8. Work with treaters during RTW plan, are changes required? Be flexible

9. Case conferencing is imperative

10.Upskill managers to have capacity to support and IW.

11. Ensure that you are not just interested in the IW’s capacity to return to

work, but their overall functioning and whole being.

• The employer did what they could to support them

• The employer made an effort to find suitable employment as part of their return to work plan

• The employer assisted with their recovery and return to work

• The employer provided enough information of their rights and responsibilities

• The employer treated them fairly before and after the claim

• Contact – early and supportive

SUPPORTING RECOVERYKEY FACTORS FOR EMPLOYEES

Mentally Healthy Workplaceshttps://www.worksafe.qld.gov.au/mentally-healthy-workplaces/overview

Psychological or Psychiatric Injurieshttps://www.worksafe.qld.gov.au/psychological-or-psychiatric-injuries

Resources to identify suitable dutieshttps://www.worksafe.qld.gov.au/claims-and-return-to-work/rehabilitation-and-return-to-work/suitable-duties/resources-to-identify-suitable-duties

Taking Action – Best Practice Frameworkhttps://www.safeworkaustralia.gov.au/doc/taking-action-best-practice-framework-management-psychological-claims-australian-workers

Clinical guideline for the diagnosis and management of work-related mental health conditions in general practicehttps://www.monash.edu/medicine/spahc/general-practice/work-related-mental-health-guideline

Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorderhttps://www.phoenixaustralia.org/resources/ptsd-guidelines/

USEFUL RESOURCES AND LINKS

WELCOMEKEY TAKEAWAYS

• Be supportive, positive and stay in contact with injured employees

• Returning to work is a necessary step in an employee’s recovery

• Employees who stay at work or gradually return to work often recover more quickly

• Offer suitable duties to support your employees

• Increase your focus on mental health in the workplace

• Psychological injuries can be costly but so can lost productivity and engagement

Thank you