Lewis, Justin --- "Challenges of managing the injured worker in a compensation scheme: a psychiatric perspective" [2017] PrecedentAULA 5; (2017) 138 Precedent 14

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CHALLENGES OF MANAGING THE INJURED WORKER IN A COMPENSATION SCHEME

A PSYCHIATRIC PERSPECTIVE

By Justin Lewis

The management of the injured worker in a compensation scheme can pose unique challenges to the treatment provider. Unlike the traditionally exclusive doctor-patient relationship, working in a compensation setting includes the addition of a third party (the insurer) into the clinical mix. As a consequence, the traditional doctor-patient dyad is challenged, with the potential to impact upon important clinical domains including: role, diagnosis, management, communication and confidentiality. In addition, the injured worker is characterised by having to deal with multiple concurrent losses. Some of these losses may include loss of employment, loss of role, loss of identity, financial loss, loss of physical function and independence. Patient symptoms regularly impact upon social, recreational and interpersonal functioning. As a consequence, individuals are often dealing with significant grief in the context of their changed life circumstances. It is therefore not surprising that secondary psychiatric conditions, such as depression and anxiety, form the basis of most psychiatric referrals.

THE EXPERIENCE OF INVALIDATION

A particular challenge when treating the injured worker is managing their experience of invalidation. Injured workers often report feeling invalidated in numerous ways in the context of a workplace injury. Management failing to acknowledge abuse or placing unreasonable pressure on an injured worker to return to work are examples. The experience of chronic invalidation can contribute further to feelings of isolation, marginalisation, disempowerment, insecurity, depression and anxiety.

Managing the patient in a compensation scheme is therefore particularly challenging. The compensation process is often perceived as additionally adversarial and invalidating by the injured worker. The practical requirement of the insurer to determine liability of a claim is often experienced by the patient as an invalidating process. For the patient, their experience of workplace injury (whether it be bullying and harassment, physical injury, pain, etc) is already well established. The experience of having to demonstrate that a condition was caused by work is not only intrinsically invalidating and undermining but also inherently inconsistent with a patient’s primary concern to have their pain or suffering alleviated.

The importance of validation to recovery

The process of verbally repeating one’s work history (often to multiple treatment providers) is frequently described as draining and exhausting. As such, patients often talk of communicating their injury history in an increasingly detached fashion, adding to feelings of despair and despondency. Therefore, it is not uncommon under the circumstances for patients themselves to subsequently question the validity of their compensation claim. Consequently, over time, the patient’s formulation of their injury is more likely to include a belief that that they have contributed to the injury somehow via some personal flaw or fault.

Being put under surveillance is another aspect of the compensation scheme that contributes to a patient’s experience of invalidation and sometimes results in significant psychological harm. Patients often report feeling unsafe, vulnerable and shamed. A patient recently placed under surveillance likened the experience to feeling like a criminal and required significant clinical support following the episode.

In addition, unfavourable reports from independent treatment providers are often experienced as particularly invalidating. The worker who is assessed as having a work capacity (despite their belief to the contrary) is often left feeling highly demoralised and despondent. Not infrequently, insurer-appointed independent examiners communicate negative views regarding current treatment approaches. This invariably erodes patient confidence and risks potentially undermining the current treatment provider. To be fair, it is particularly challenging for independent treatment providers who assess patients cross-sectionally to fully appreciate the worker’s experience. This is especially relevant in the case of psychiatric assessments, in which there is frequently only limited time to gather and formulate what is often a complex history. In addition, assessments are invariably complicated by the patient’s perception of the treatment provider being aligned with the insurer and therefore biased.

Patients in a compensation scheme are in an invidious position: dependent on the system for financial/medical support while concurrently feeling invalidated and devalued by that system. As such, the unique challenge of the treatment provider in insurance-related matters is to maintain the validity of the worker’s experience at all costs. Once despondency and demoralisation have become entrenched, the patient is unable to take control of their own recovery. They become less likely to take positive and resourceful steps to improve their circumstances. In light of the above, validating the patient’s experience remains the cornerstone of psychological treatment. If we do little else but reflect back to the patient that you can understand and empathise with their experience, then you have often created the pre-conditions for a healing process. Often validation in itself is sufficient for an injured worker to begin to mobilise their inner resources in order to navigate a recovery pathway.

The value of group therapy

In addition to individual therapy, I have found group therapy to be a particularly validating environment for the injured worker, particularly for those whose progress has stagnated. I first ran general group workshops (open to all patients) seven years ago, focusing on self-esteem. Within a short period of time, the group evolved into a dedicated group for injured workers as they readily responded to affirming feedback from other group members. Many patients report that they only began to genuinely feel understood after their work experiences had been shared and acknowledged by other injured workers. As such, the group represents a place where they can share their experiences in a safe, non-judgemental and supportive fashion.

In addition, group therapy can be a particularly therapeutic environment for individuals dealing with grief and loss; perhaps another reason why group therapy appeals to the injured worker. Patients in the group who have been able to integrate their changed life circumstances can become a beacon of hope to those who are in the earlier stages of change.

THE IMPACT OF THE COMPENSATION SCHEME CONTEXT

Providing care for a patient in a compensation scheme is complicated by the fact that the treatment provider is not just managing the individual, but the individual as part of a complex system. As such, one should avoid an exclusive focus on clinical symptoms and maintain an awareness of the broader systemic issues that the patient faces. This approach will likely lead to a patient who feels supported throughout the compensation process. It is therefore incumbent on the treatment provider to have some familiarity with the insurance system if the patient is to feel genuinely supported. A treatment provider with experience dealing with the insurance schemes is better placed to guide the patient through the process and temper expectations. This invariably enables the treatment provider to focus on both the clinical and broader systemic issues in a more pragmatic fashion. The treatment provider who becomes emotionally invested in the outcome of insurance matters can invariably leave the patient feeling that nobody is in control.

Another significant advantage of understanding the compensation process is that the treatment provider will be better placed to act in an advocacy role. This is an important role, as the injured worker invariably presents with lowered self-esteem and self-efficacy in the context of work-related difficulties. The insurer is often perceived as adversarial, and many patients simply cannot meet their obligations in relation to the insurance process. For patients who have been severely bullied and harassed at work, dealing with the insurer can be similarly traumatic. As a consequence, the treatment provider plays a very important role in representing the patient’s interests and needs, at a time when they lack the psychological resilience to do so for themselves.

Patient confidentiality

An additional challenge when treating patients in a compensation scheme is patient confidentiality. The patient often does not have the same confidentiality privileges that are critical in any therapeutic relationship. Issues of confidentiality also affect the treatment provider who is obligated to provide clinical feedback to the insurer indicating opinions regarding issues such as diagnosis, treatment and prognosis.

Treatment providers can often feel resentful and adopt a protectionist view if they perceive the insurer’s request for information as being unnecessarily invasive. This can sometimes be counterproductive, particularly when positive patient outcomes rely on effective communication channels between treatment provider and insurer.

The need to provide information to the insurer regarding diagnosis has the potential in certain circumstances to strain the therapeutic relationship. It can be particularly challenging as a treatment provider when your view of causation or vulnerability factors in the aetiology of a workplace injury is at variance with the patient’s view. Recently, a patient I reviewed presented complaining of predominant workplace stress, but had under-appreciated the contribution of chronic marital strain. It was incumbent on me to share this with the insurer. The patient was not yet ready to acknowledge that their marriage was breaking down and was unfortunately left feeling heavily confronted. A more extreme example concerned a patient complaining of workplace harassment who had no awareness of the fact that they were suffering from a paranoid psychotic illness. Ordinarily, one has the time to allow the patient to gently assimilate a broader perspective of contributing factors. However, the requirement to have to communicate a view on causality to the insurer, particularly when such a diagnosis is at variance with the patient’s understanding or level of insight, can undermine the therapeutic relationship from the outset.

BARRIERS TO RECOVERY

A unique challenge of working with compensation patients is the recognition that patients can have conflicted feelings about their recovery. The very nature of a compensation scheme, from the patient perspective, can involve inherent conflict. The patient wishes to recover in a clinical sense and return to normal functioning, but, on the other hand, they understandably wish to maintain the support they receive from the insurer during a period of significant vulnerability. For some patients (particularly those who have been severely harassed or traumatised at work) there can be unconscious factors maintaining a reliance on the insurance scheme, particularly when a return to work is accompanied by marked phobic avoidance. Reticence by the patient to acknowledge clinical improvement to the treatment provider can be one example of how this quandary manifests in the clinical setting. In my experience, it can be helpful to openly discuss and acknowledge, factors that may be contributing to ambivalence in a recovery sense. With that said, the reticence of the patient to communicate improvement is understandable, particularly in compensation scheme context where one need demonstrate only a modest improvement in symptomatology to be made ineligible for critical benefits.

GETTING TREATMENT APPROVED

Another particularly challenging aspect of managing the patient in a compensation scheme context is arranging for necessary medical or ancillary services to be approved. In my experience, it is not uncommon to have to make repeated requests to insurers for basic clinical interventions. Often significant time is lost in the process of seeking approval, consequently postponing important intervention and the improvement in patient health that is likely to result. This can be a frustrating experience for both patient and treatment provider, particularly when timely additional support is required. The task of finding a treatment provider (for example a psychologist) to provide additional support for an insured patient is one such challenge. Many treatment providers are now reluctant to take on the insured patient as a consequence of bureaucratic requirements, and difficulties in being remunerated in a timely fashion. The background ‘threat’ of medical services being terminated at some future point can cause anxiety for both treatment provider and patient, particularly for those patients who cannot afford private care.

THE STRESS OF LITIGATION

As a treatment provider, I have noticed that a patient’s recovery in a psychological sense is potentially undermined when litigation is pending. The patient in a compensation scheme is invariably dealing with the concurrent stress of recovering from a medical illness in addition to managing a compensation claim. At some point, the worker’s entitlements are reviewed at conciliation, by medical panels or tested in various aspects of the legal system. For many, this process is daunting and frequently accompanied by psychological set-back. In many instances, individuals do not have the resilience or fortitude to deal with pending hearings. Deferred legal hearings after a prolonged and anxious wait can lead many to feel particularly defeated and despondent. The reality is that litigation can take years to be resolved and can be a significant distraction from the clinical issues. As a treatment provider, one often has to accept the reality that, in many instances, a genuine focus on recovery cannot occur until the completion of litigation. In such cases, my practice is to take on a supportive role through this stressful time, focusing on building resilience and preventing setbacks.

THE STIGMA OF COMPENSATION

To the treatment provider, patient stigma associated with being in a compensation scheme is often readily observable. Patients describe various degrees of shame, which sadly often reflects cultural attitudes toward the compensation patient. In many instances, shame is a manifestation of the perceived failure of an individual to maintain employment, even in circumstances in which the barriers to returning to work are undeniable. Addressing shame (even when it is not overtly demonstrated by the patient) is an important part of the clinical process. Shame (when not addressed) can act as a psychologically toxic emotion that can undermine recovery. Unfortunately, many aspects of the compensation process can be experienced as shaming. In particular, the finding of an independent medical examiner that an individual’s condition is ‘no longer work-related,’ can readily be experienced as delegitimising and consequently shaming. Once again, group therapy can help the injured worker by addressing ‘compensation-related shame’. The power of shame to undermine recovery is diminished when spoken about in a safe, non-judgemental group environment. Our group therapy mantra – that ‘bad things can happen to good people at work’ – helps individuals to normalise their work-place difficulties, encourage positive self-esteem and build empowerment in a recovery sense.

CONCLUSION

In summary, the management of the compensation patient can pose a number of challenges from a psychiatric perspective. It is therefore not surprising that many psychiatrists are not prepared to treat the compensation patient. This is potentially concerning given the psychological vulnerability of injured workers and the risk of secondary psychiatric difficulties. An awareness of the common issues that arise for the treatment provider and patient can be invaluable in pre-empting and managing such challenges. In addition, the importance of providing a safe and validating environment for the individual cannot be overstated, given that the compensation process is frequently perceived as adversarial. Furthermore, group therapy offers a unique environment in which the injured worker can address despondency and instil hope.

Dr Justin Lewis MBBS, BMedSci, MPsychMed, FRANZCP is a consultant psychiatrist in private practice at Delmont Private Hospital, Melbourne. He also has an extensive medico-legal practice specialising in personal injury matters and a longstanding interest in providing care for compensation patients. EMAIL [e-mail].