Refers to psychological and social factors involved with injured workers
returning to work.
Examples of psychosocial factors that affect return to work area
include:
A personâl belief about how they will cope with their condition,
the attitude of the injured worker's family to their condition and return to work,
the employer's return to work policy and the influence of the WorkCover
system on a person. factors that can influence the self-assessment of function.
(Journal of Occupational Rehabilitation; 14(3):197-206Department of Psychiatry,
The University of Texas Southwestern Medical Center at Dallas, Dallas,
TexasBackground, Study Objectives, )
How It Was Done:
This paper's author suggests that many factors can influence the assessment
of a person's level of pain and their ability to function. Therefore, it is best to
approach assessment by taking into account this broad range of factors, rather
than using one simple measure.The aim of this paper is to better understand
the factors that can influence assessment of function and recovery. The paper
reviews some evidence from previous studies, and then recommends an
approach for assessing a person's ability to function after sustaining injury.
Study Findings:
The following factors can influence a persons beliefs and approach to recovery
and in turn can affect their return to work. Each factor needs to be understood
in order to be addressed. While this can be difficult it can make a significant
difference.Secondary loss issuesSecondary loss can be a barrier to recovery.
Some types of loss that can be caused as a secondary result of injury are:
Economic loss
Loss of relationships at work
Loss of social support networks
Social stigma of being disabled, or on workers compensation
Guilt about disability
Loss of recreational activities
Loss of respect from family and friends
The papers author indicates that these losses can have a cascade effect,
leading to significant emotional distress. This then complicates the physical
problem. Effective management of return to function acknowledges
secondary loss, and assists the patient to address these problems positively.
Secondary gain:
Secondary gain has been defined as "the interpersonal or social advantage
obtained by the patient as a consequence of illness". Secondary gain is a
normal facet of life. For example, a person with a headache may not have
to do the dishes, and someone with a cold may spend a day at home rather
than at work. It is a normal for people to experience secondary gain.
Secondary gain:
Any indirect gain that occurs as the result of an injury or illness.
For example, financial gain (in the form of compensation), not having to
work, sympathy or attention. in a modest way.However in some circumstances
the secondary gain becomes a significant issue, and can interfere with return to
function. Secondary gain can range from fulfilment of token needs and wishes
(such as to be taken care of, to change family dynamics or to get even when
blame is involved) to more material issues (such as financial gain, or avoiding
work while maintaining income).It is often said that financial compensation
encourages disability.
Disability:
A condition or function that leaves a person unable to do tasks that most
other people can do. If patients are paid to be sick, they may learn to continue
to seem to be sick, as using this behaviour brings them reward. It is often
expected that people will return to normal functioning when they are no
longer receiving compensation for their injury. However, when the financial
reward stops, the authors of this paper suggest that the behaviours often do
not change. People can continue to behave in a way that allows them to avoid
activity.The authors also go on to suggest that treating practitioners shouldn't
assume that patients with financial secondary gain issues cannot be treated
effectively.
Studies have shown that even in the presence of unresolved financial gain
claims, treatment outcomes can be positive. One of the risks of focusing on
secondary gain is that it deters the treater from appropriate treatment,
may result in poorer outcomes.It is recommended that the treating
practitioner
Treating practitioner:
A health professional that treats patients. In return to work this may
include doctors, physiotherapists, chiropractors, osteopaths, psychologists,
masseurs, etc. take into account the persons situation and any barriers to
recovery, and focus on improving their level of function. The focus should not
be on freeing the patient from pain, but rather on supporting active
rehabilitation.
Management of this situation includes:
Defining a medical endpoint:
Arranging a treatment plan in communication with all parties, with the
aim to return to as normal a life as possible. This may involve family
members, other health care providers, claims managers, and employers.
The team should:
Establish trust and rapport with one another
Plan the return to work
Address any financial issues, including secondary gain, and provide the
person with an understanding of the financial implications
Set goals, including the injured person in this process
After trust has been established, educate the patient about their
reasonable expectation for recovery.
Emotional distress:
Changes in a person's mood often accompany pain and in turn this
affects function. Studies have indicated that 40 to 50% of all chronic
pain patients experienced some form of depression.
Continuing a long time or recurring frequently pain patients:
Experience some form of depression, Anxiety is also common.
People who are fearful of pain avoid activity that they think may cause pain.
They often experience more distress and secondary loss.
Secondary loss:
Any indirect loss that occurs as the result of an injury or illness.
For example, loss of social contact with work friends, loss of status,
financial loss from reduced income. issues. The fear of pain prompts
avoidance behaviour and retreat from normal daily activities. In turn
this leads to increased social isolation, inability to return to function and
prolonged disability.Anger is also becoming recognised as an emotional
state that can affect function. Anger may be directed at persisting
symptoms, unsuccessful treatment, a person blamed for the injury, the
workplace where the injury has occurred, the workers' compensation
system, any delay in management, or family, or colleagues who may be
unsympathetic. Anger that is not expressed is associated with increased
intensity of pain and perceived interference with activities of daily living.
People who are angry seem to be less motivated to respond to assessment
or treatment.
Other factors the author notes influence a persons level of distress are:
Uncertainty about:
How they should manage the condition
The likely outcome (how long the condition will take to improve and
whether the condition is likely to leave them with long-term problems)
The best treatment
Feelings of being misunderstood
Lack of understanding about their entitlement, such as delays in being paid,
difficulties in sorting out the level of pay, etc.Symptom magnification. It is
rare that a patient is consciously faking functional disability. Symptoms
may be exaggerated consciously, or unconsciously, as a way of expressing
the person's illness.
Compliance and resistance issues:
Fear and trust can be major issues for some people, and can interfere with
their willingness, or motivation to participate in a rehabilitation
Rehabilitation :
The process of helping a person back to their former abilities and quality of
life (or as close as possilble) after injury or a medical condition. program.
These issues need to be dealt with in a supportive and educational manner.
It may take some time to develop a level of trust that supports a collaborative
working relationship to overcome these barriers.
Patient Comprehension:
Practitioners tend to assume that patients understand discussions and any
reading material. However, some information needs to be presented a
number of times, or in different ways for patients to fully grasp its meaning.
It is important that the treating practitioner recognise when a patient does
fully understand the information and advice given about their condition.
Iatrogenic effect :
An unwanted negative health effect that occurs as a result of treatment.
E.g. side effects of medication, the problems that can occur from a person
being told to rest, a complication from surgery. An iatrogenic effect it is an
unwanted effect inadvertently introduced by a health care professional, or
treatment. For example, after being advised to rest to relieve pain a person
may continue to rest for longer than necessary. In turn this can change the
person's behaviour, or beliefs in response to their condition and alter their
routine. It is important that treating practitioners understand this issue,
so that appropriate advice is given.
Conclusions:
This study notes that there are many factors that influence a patient's
return to function and their assessment of their own ability and recovery.
Acknowledging and dealing with secondary loss and secondary gain issues,
emotional distress, and the potential for treatment to cause unwanted effects
is needed to accurately assess function. These issues can be complex, but the
authors indicate that they can be effectively addressed with adequate time,
& communication and the development of trust.
Original Article, Authors & Publication Details:
R. J. Gatchel1 (2004).
Psychosocial factors that can influence the self-assessment of function.
J Occup Rehabil. 2004 Sep;14(3):197-206. Review.
PMID: 15156778 [PubMed - indexed for MEDLINE]
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