Early Psychological Intervention
with Physically Injured Workers
‘Resilient Tomorrow’
TIO Conference
October 2014
Scott Bevis
Clinical Psychologist
Dynamic Minds Psychology
Overview
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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
80%
70%
60%
50%
40%
30%
20%
10%
0%
20 days
45 days
Time off work
10 weeks
12 months
(AFOEM, 2012)
Return to Work Rates at 7-9 months
The social research centre, 2013
The chances of returning to work
80%
70%
60%
50%
40%
30%
20%
10%
0%
20 days
45 days
Time off work
10 weeks
12 months
AFOEM Position statement 2012
Contributors to the problem
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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 nonresponsiveness
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
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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 Flags
Red
Yellow
Indicator of serious biological pathology
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
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Fear avoidance beliefs/behaviour
Catastrophic thinking
Stress & anxiety
Depressed mood
Low self efficacy
Passive coping styles
Depression (MDD)
Anxiety disorders
PTSD
Personality disorders
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Perceived injustice
Inadequate support
Excessive demands
Low morale claims*
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Toxic workplaces
Scope of RTW options
Legal orientation
Poor claims handling*
Yellow Flags
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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
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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 Questionnaires
Risk 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 Tool
Shaw Back pain Disability Risk Questionnaire
Perceived injustice
Injustice Equity Questionnaire (IEQ)
Justice Sensitivity Inventory
Perceived
organisational support
Survey of Perceived Organisational Support
Perceived 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
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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 162 339
Email: dynaminds@bigpond.com