Early Psychological Intervention with Physically Injured Workers

Scott Bevis Clinical Psychologist

Dynamic Minds Psychology

‘Resilient Tomorrow’ TIO Conference October 2014

Overview

• The problem at hand• Work injury & the biopsychosocial model• Risk factors for poor outcomes• Early psychological intervention • Barriers to early intervention

The Problem at Hand

• The longer a person is absent from work due to illness or injury, the lower their chance of ever returning to employment (AFOEM, 2012)

• The longer an employee remains in a worker’s compensation system, the poorer their return to work and health outcomes will be (Konekt, 2013)

• Chronic pain is Australia’s 3rd most costly health condition with an estimated economic cost in 2007 of $34 Billion (Access Economics, 2007)

The Chances of Returning to Work

20 days 45 days 10 weeks 12 months0%

10%

20%

30%

40%

50%

60%

70%

80%

Time off work (AFOEM, 2012)

Return to Work Rates at 7-9 months

The social research centre, 2013

The chances of returning to work

20 days 45 days 10 weeks 12 months0%

10%

20%

30%

40%

50%

60%

70%

80%

Time off work AFOEM Position statement 2012

Contributors to the problem

• Adherence to the medical model • Individuals..... we are all unique • Compensation systems • The neurophysiology of pain

The Medical Model

Core assumptions• There is a linear relationship between injury, symptoms &

disability• That by treating the underlying pathology the patient will get

better

Limitations • Neglects the significance of the personal & contextual

dimensions of injury and recovery• Implicitly encourages passive recovery behaviour• Colludes with patients’ unhelpful ideas about pain & recovery• Treatment is escalated sequentially based on non-

responsiveness

The Uniqueness of People

Individuals bring along their own experience• Thoughts, attitudes, & beliefs • Feelings & emotions • Actions & behaviours

As informed by;• Demographics, education, health literacy, personal &

family history, personality & interpersonal style, etc.

Compensation & Recovery• The purpose of workers’ compensation insurance is to facilitate optimal recovery and return to work following injury

• The compensation hypothesis - patients within compensation systems have worse outcomes than non-compensable patients

• The evidence is not conclusive (Spearing et al, 2012)

• Claimants do encounter additional factors – Dealing with the claims and settlement process – Exposure to medico-legal assessments, – Perceived lack of trust about having to prove an injury or disability. – The necessity of legal representation– Embitterment toward the system – strong sense of entitlement & injustice– An inability to move on with life during the claims process, (Mergatroyd et al. ,2011)

Neuroplasticity & Chronic Pain • Pain lasting beyond the expected healing time for the

damaged tissue (3-6 months)

• Has a distinct pathology separate to the catalysing injury

• Associated with changes in the nervous system that continue to worsen over time

• Contributes to ongoing decline in physical & psychological wellbeing

• Poorly understood by patients (and treatment providers??)

• Best treated via a multidisciplinary approach (Pain Australia, 2014; US Institute of Medicine,

2011)

Biopsychosocial Model

Adoption of the BPS model

Now recognised & promoted by workers’ compensation authorities in Australia & NZ • The Clinical Framework for the Delivery of Health

Services (Victorian WorkCover/TAC) *• The NSW WorkCover program and guidance• The ACC Pain Management Services (NZ) • Nationally Consistent Approval Framework for

Workplace Rehabilitation Providers (HWCA)*

Risk Factors for Poor Outcomes

• In the context of work injury, there are numerous psychosocial factors that impact recovery

• These factors are often identifiable around the time of injury and if left unattended often become the maintaining factors

• The Flags concept was introduced as a framework for understanding and evaluating the personal and contextual elements as ‘risks factors’

• Whilst not diagnostic ‘Flags’ signal specific obstacles to recovery and indicate where extra attention is required

• Provide a standardized language for dialogue about these features in everyday practice and between disciplines

(Kendall & Burton, 2009)

Types of FlagsRed Indicator of serious biological pathology

Yellow Beliefs, thoughts and attitudes about injury and context

Emotional Responses to injury and context

Pain Behaviours (coping style, how relate to injury)

Orange Psychiatric symptoms

Blue Perception about the work and injury relationship

Black System and contextual barriers

Flags in the BPS Model

Psychosocial Risk Factors • Fear avoidance beliefs/behaviour• Catastrophic thinking • Stress & anxiety• Depressed mood • Low self efficacy • Passive coping styles

•Depression (MDD)•Anxiety disorders•PTSD •Personality disorders

• Perceived injustice • Inadequate support • Excessive demands • Low morale claims*

• Toxic workplaces• Scope of RTW options• Legal orientation• Poor claims handling*

Yellow Flags

• Fear avoidance beliefs/behaviour• Catastrophic thinking • Stress & anxiety• Depressed mood • Low self efficacy • Passive coping styles

(Nicholas et al, 2011)

Early Psychological Intervention

The risk factors for poor outcomes are known

These factors are identifiable at or around the time of injury

The aim of early psychological intervention is to;• Assess for the presence of psychosocial risk factors, and when indicated • Address the risk factors to reduces the potential for poor health and poor RTW outcomes

Early Psychological Intervention

Why psychologists?• Experts in mental health • Trained & experienced in the BPS model, psychological assessment

and relevant evidenced based treatments• Understand the significance of normal risk factors and capable of

discriminating between the flags

Why early? • Address psychosocial factors acutely or sub acutely to prevent

‘chronic pain’ becoming the presenting problem• Normalise the reality that psychosocial factors inform the

experience of pain and recovery outcomes• Prevent the occurrence of secondary psychological injury

Psychological Assessment

The purpose of early assessment

• Identify relevant risk factors (differentiating between the different flags) and make recommendations on treatment requirements

• Triage who would benefit from psychological treatment based on identified risk factors

• Inform patients, treatment providers & stakeholders about the identified risk factors, how they impact recovery & how they might be addressed

Psychosocial Assessment

Clinical Interview • Identify thinking styles & beliefs about being injured, • Explore contextual factors & ideas about recovery, • Determine how patients relate to being injured at work

Screening Questionnaires• Validate against data collected at interview• Evaluate the ‘size’ of a risk factor• Communicate in quantifiable figures • Baseline factors for monitoring of treatment effect

Screening QuestionnairesRisk factor Measure

Fear avoidance beliefs/behaviour

Fear & avoidance beliefs questionnaire (FABQ)Tampa Scale of Kinesiophobia (TSK)

Catastrophic thinking Pain Catastrophising Scale (PCS)

Stress, Anxiety Depressed mood

Depression Anxiety Stress Scale (DASS 21) Kessler’s Psychological Distress Scale (K-10)Positive and Negative Affect Scales (PANAS)

Low self efficacy / Passive coping

Pain self-efficacy questionnaire (PSEQ)

Perceived function, disability & pain

Pain Disability Index (PDI)Brief Pain Inventory (BPI) Oswestry Disability Questionnaire

Screening Questionnaires Risk factor Measure

Composite measures The Orebro Musculoskeletal Pain Screening Questionnaire.The Start Back ToolShaw Back pain Disability Risk Questionnaire

Perceived injustice Injustice Equity Questionnaire (IEQ)Justice Sensitivity Inventory

Perceived organisational support

Survey of Perceived Organisational SupportPerceived psychological contract breach (PCB)

PTSD Post traumatic Check List - Civilian (PCL-C)

Personality types Personality Assessment Inventory (PAI)Millon Clinical Multiaxial Inventory (MCMI-III)

Early Psychological Treatment

What should be occurring in treatment • Education with patients about the nature of pain & how

psychosocial factors inform the pain experience• Addressing identified yellow & blue flags with patients via

specific education & evidence based treatment (CBT) • Establishing with patients a recovery plan that is goal focused

and measureable• Raise awareness and start the conversation early with

stakeholders about collaborative solutions to identified blue & black flags

• Engagement and collaboration with the treatment team

Early Psychological Treatment

Problematic psychological treatment • Unnecessarily pathologising the patients’ experience • ‘Hand holding’ therapy or harbouring the patient • Failing to inform patients about the psychosocial risk• Not having or sticking to a treatment plan• Not measuring treatment outcomes• Continuing treatment when it is not working• Unnecessarily addressing underlying psychological issues• Not communicating with stakeholders about patients

Evidence on Early Intervention

Treatment targeting identified risk factors results in Better outcomes compared to;• Interventions that ignored the psychological risk factors

• Interventions that assume all physically injured workers have risk factors and require psychological input

These findings indicate that; • Assessing injured workers to identify risk factors is an important

precursor to psychological treatment

• Simply applying psychological treatment to all patients is counter productive and uneconomical

(Nicholas et al, 2011)

Evidence on Early Intervention

Outcomes are significantly improved when; • Yellow flag are addressed in conjunction with

blue & black flags being addressed via targeted workplace interventions

These findings highlight the criticalness of;• Early psychosocial assessment • Early psychological treatment when indicated • Early dialogue between stakeholders to address

risk factors beyond the injured workers’ control(Nicholas et al, 2011)

Barriers to Early Intervention

• Fusion to the medical model• Ignoring psychosocial factors as normal & part

of the ‘compensable injury’• Cost & Liability concerns• Stigma and professionals’ ignorance• Access to psychological services• Patient resistance

Questions Now or Later

Scott Bevis Clinical Psychologist Dynamic Minds Psychology

Ph: 0400 162 339Email: dynaminds@bigpond.com