This interview with Dr. Gaffney first appeared in the May 1997 issue of The Authority,
a news magazine produced by Colorado Compensation Insurance Authority.
© 1997 by Colorado Compensation Insurance Authority.
Reprinted with permission
Clinical psychologist Kevin Gaffney, Psy.D., has been evaluating and treating injured workers for the past 10 years in his private practice in Greeley. Dr. Gaffney is a member of CCIA's SelectNet Referral Network, consults and provides training workshops to insurance carriers and corporations regarding the role of psychological service in the Worker's Compensation system. He's also been working closely with occupational medicine physicians on the research and development of data-based effective diagnostic and treatment protocols for injured workers. In this interview, Dr. Gaffney addresses the role of psychology in the diagnosis and treatment of injured workers and issues that affect the recovery of injured workers.
Q. What has been psychology's role in the Worker's Compensation system?
A. Psychology in Worker's Compensation has been viewed much more favorably in the last ten years. Prior to that, there was little consideration of the psychosocial factors involved in a work-related injury and reactions to the injury. Psychology traditionally has been involved at the very end after medical treatment has failed. Just a few years back, if nothing seemed to work after numerous medical procedures and a number of years, the patient was told they needed counseling. The underlying message to the patient was that it's 'all in your head.'
We are now talking about psychological involvement at four to six weeks. It could also be after the first visit in terms of the need to assess an early psychological intervention. Psychology is beginning to be moved up the time line from the last treatment procedure that's involved to early diagnostic evaluation. This is to identify risk factors predictive of delayed recovery. Also, it helps to determine what psychologically is related to the injury. Lastly, it prescribes an appropriate and reasonable treatment plan based on what is work related.
Q. Why should psychology as a discipline be involved at all?
A. A Worker's Compensation injury is not just a medical problem, it's an example of a complicated bio/psycho/social phenomenon. There are myriad factors that can be involved. The psychological factors can be reactions to the injury or contributors which exacerbate complication(s) to the injury.
Physicians, however, shouldn't refer people to get psychotherapy counseling simply because the medical treatment doesn't appear to be working or progressing into "delayed recovery." You have to consider that diagnosis directs prescription. In medicine, an X-ray dictates whether a cast is put on an arm or surgery is indicated. In psychology, diagnostics or evaluation always must proceed any type of indicated treatment or else you're going to have a problem I have referred to as Pandora's Paradox.
Q. Pandora's Paradox?
A. Pandora's Paradox refers to the common knowledge that there are psychosocial factors involved in some injuries which significantly influence delayed recovery. However, there is a reluctance to open the box and address them. This can be a costly mistake not to look at them. There is a fear of opening Pandora's Box: "If I see it, I'll be responsible for it." However, avoiding the box does not make it go away. These psychosocial factors drive tremendous complications in the system, and in the failure to respond to medical treatment. The reality is that these patients are and will continue to be the biggest consumers of health care dollars. As a rule, I think a physician should first obtain a psychological evaluation before performing surgery or treating difficult cases where delayed recovery is evident.
The paradox is the fear of being responsible for taking on a problem that is driven by factors that don't have anything to do with the specific injury. And that's an understandable reaction.
Q. What do you mean by delayed recovery?
A. Delayed recovery is essentially when a person is not responding to medical treatment within the normal time frame in which a physician would expect progress to occur. We find that there is, in a small percentage of the time (about 5 percent), an inaccurate medical diagnosis. But it is well known that the major contributors that primarily drive delayed recovery patterns are psychosocial factors.
Q. What are some of the psychological factors which lead to a delayed recovery?
A. Some of the contributors are particular long-term personality patterns, the level of heartiness or perseverance in the person's personality, cultural factors, economic factors and, of course, the legal factors that become a prominent influence in the course of rehabilitation. So we're dealing with a multifactorial phenomenon and to ignore that kind of systematic perspective really is quite costly in terms of medical outcome and financial cost.
When you start to look at delayed recovery, factors such as depression and anxiety, early life abuse, compromised motivation, and personality disorders really drive that phenomenon.
Depression compromises motivation. Many times patients might be referred to as non compliant but are just helplessly depressed because every where they turn, nothing seems to be helping. Thus what a patient begins to believe about their condition becomes very important. And what the patient thinks and believes may be very inconsistent with what the physician is saying to them. The physician is correct, but the patient interprets it and believes differently.
Q. Talk more specifically about the increased financial costs and decreased medical outcomes.
A. There is a common rule that came up about 10 years ago, the 80/20 rule. For example, in low back pain injuries, 80 to 90 percent of all people who sustain a back injury are back to work within a three-month time period regardless of the severity of the injury. The 10 to 20 percent that are not back to work account for between 80 and 90 percent of the medical costs.
There were some very impressive studies conducted by Stan Bigos, an orthopedic spine surgeon at the University of Washington, who asked psychologists to work with him. Bigos found in looking at many medical factors in the 10 percent who had not returned to work, that the medical factors did not really predict a delayed recovery pattern. It wasn't just that the several psychological and social factors that predicted those delayed recovery patients, it was the significance of how well these factors predicted delayed recovery. In terms of financial costs, a few people are responsible for relatively lengthy treatment and huge costs, while 90 percent are usually back to work.
Q. Explain this in the context of your theory on the 'adult failure to thrive' and how that affects recovery.
A. We have to look at the role of early attachment disruption to explain this. When attachment gets broken, the ability to deal with pain and frustration gets warped or retarded. What I often find in really complicated delayed recoveries is when this type of detachment history is present, there is an inability to identify and express emotion. They essentially are unable to say, "I can't feel comfortable." A physical injury, such as a strain, can become a (psycho) logical focal point to resolve underlying needs for nurturance and comfort. The person cannot handle being uncomfortable. This feeling becomes disabling to the person and the physician gets confused because the discomfort shouldn't be this intense. The person just continues to linger medically. The injury and the way it makes the person feel addresses an underlying, albeit unconscious, deep need for nurturing and dependence that is being provided by the medical system. The patient might actually be quite offended if told that their needs for nurturing and dependence were driving a lot of this complication.
I refer to this syndrome as the adult failure to thrive; at some point in time, life begins to wear at them. They might not have had the most positive of psychological, social, and educational histories. So when the system just keeps treating them medically, it's not addressing this inability to thrive usually caused by disruptions in their early childhood.
I believe many physicians who aren't familiar with the Worker's Comp system will say that Worker's Comp patients don't recover as well as non-Worker's Comp patients. While there is some validity to this, it's doing an injustice to the 90 percent who do recover normally. People who have developmental histories and psychosocial risk factors do have a poorer response to medical treatment. These are the types of cases which give the Worker's Comp patients a bad reputation, and often times medical professionals will not want to get involved with the case.
Q. What can psychologists do to correct this misconception?
A. By entering into the treatment process earlier and working with the physician, we can help that 10 percent get back to work sooner. Psychologists have multiple roles; one role is as a consultant to the physician and physical therapist. He/she can help in identifying the psychosocial factors following a diagnosis or assessment. Assistance can be given to the medical providers on how to respond to a patient so as not to reinforce disability and complications and instead maximize autonomous behavior and recovery.
The cancer surgeon Bernie Seigel put it into perspective. He said that over the years he's not as concerned with the medical diagnosis as he is with the type of person who has the diagnosis. We're really talking about why some people can have an injury, go through a surgical procedure, and recovery fully, and why another person can have that similar or lesser an injury, go through a similar procedure and report an opposite reaction. What determines that? In some ways, it's trying to get a handle on the spirit of the individual and their coping and adaptive capacities.
Q. What are some of the repercussions in delayed recovery in Worker's Compensation cases?
A. With delayed recovery comes the issue of identity disturbance. This becomes a major concern psychologically. What is the first thing you're asked by a person who doesn't know you well? It's "what do you do? What is your job?" We don't often stop to think of who we are. Our identity often is based upon our function of what we do. Thus, anybody who has had any lapse of employment finds it a struggle socially to be out in the world. The question being, who am I if I'm not my job?
When that identity is taken away on the date of injury and the claim progresses past when medical recovery was expected to happen, we begin to get very concerned about this person beginning to view him or herself as disabled and handicapped. Once a person views that, regardless of what you find medically, motivation is going to be greatly compromised.
Q. Have any psychological tests been developed specifically for the injured worker?
A. Yes, two of my partners have developed a psychological test, "The Battery of Health Improvement." The test indicates, for example, when it is average "or normal," for an injured person to be depressed by comparing the person to the injured and non-injured population at large. Importantly, it allows us to compare average scores on injured workers. This permits us to determine if an injured worker is having "abnormal" findings compared to other injured workers. But when you compare their scores to the normal population, injured workers are more depressed. Also in that study, 71 percent of females who were delayed in recovery had histories of abuse. The problem is to identify earlier the factors that will complicate medical treatment and then decide what we do about it.
Q. Is any progress being made toward earlier identification of these factors?
A. We have developed another screening index called the SPRII, short for the Screen for Psychological Risk in Injury and Illness. It was developed to help the physician objectively give an initial impression regarding whether the patient has some sort of psychosocial involvement with their medical condition. As doctors use this index, they may observe and rate such things as: extreme or inappropriate emotion, such as despondence, being highly dramatic, showing anger or a lack of emotion; excessive compensation focus which could compromise motivation; substance abuse; excessive medication; noncompliance with a treatment plan; and conflict with an employer. The physician rates these factors if they are unusual, exaggerated or inconsistent with objective findings.
In the Bigos' study, the number one predictor of delayed recovery was job dissatisfaction, or more specifically, dissatisfaction with one's immediate supervisor. When you observe this reaction, you know the injured worker doesn't want to go back. He may be dissatisfied with the work for many reasons, such as personality clash with a supervisor. This may be understandable if the supervisor is not a pleasant person. But, you have a psychosomatic solution at play because on some level the rationale may be, "I have to feed my family, and I can't literally tell you to take a hike, boss. So my back will hurt and then I don't have to put up with you." This resolves an interpersonal conflict by avoiding it.
Q. How do employers exacerbate this situation?
A. Frequently an injured employee will say, "You know those so-and-sos didn't call me once." One of the things Bigos did in his research about job dissatisfaction was to ask supervisors to call injured workers every week just to say, "How are you doing? We look forward to having you back." The return-to-work rate started to go up as this rather common sense, family-like attitude was conveyed.
So one of the things employers should not do is to take the attitude or convey the messages to the employee like, "You're an object. You're not working and we don't need you. We can put somebody else in that position."
I think it's important that a system is set up which requires injured workers to come back to the workplace. The longer a worker stays away from the workplace, the easier it is to stay away. When a worker is in the workplace and sees coworkers, the message is conveyed that "you're still part of the family."
Q. What should employers do?
A. Employers need to be held accountable when costs are increasing because of injured worker job dissatisfaction. This can be primarily a management issue. There are other reasons why workers may be dissatisfied: they are burned out with what they are doing, don't want to go out when it's ten degrees below zero, they have to make a change in their own personal life, or they are just difficult people. You have to find out what is driving the job dissatisfaction.
I think companies can certainly get educated about the way they treat a worker and how that relates to the "bottom line" because that's one of those red flag factors that will unequivocally predict delayed recovery. Often companies don't seem like they want to pay attention to research findings and what clinical experience is telling us.
Q. What would be the most important things employers should do to impact their bottom line?
A. There are two things: first, I think it should be policy that someone from the company immediately sit down with the worker following the injury and go over benefits and let him or her know that they will work together to get the worker recovered and back to work. Spell out the process from the company's point of view, how it proceeds and address the worker's concerns. While it is difficult to talk about, sensitive questions should also be addressed, especially in more serious injuries. For example, "What happens if the injured worker is not back to work a year from now? What if this injury has ended their career? What if this doctor says they can't do this job, what else is available?" Employers need to be straight forward, to reassure and also make the worker aware that there may be some hard realities to deal with.
The second thing is for employers to consistently contact the injured worker and see how he is doing. It doesn't take a lot of time and energy to extend some common courtesy and concern. Reassure them with, "We're with you, and if you have a problem or concerns through this, let's talk about it." I think that concern and courtesy could abort the need to create an adversarial litigious situation a lot of the time.
Q. As a member, what do you see as some of the advantages of using SelectNet?
A. One big plus for SelectNet is that doctors can make referrals within the network and get additional treatment approved quickly. With most Worker's Compensation carriers, the many levels of authorization needed frustrates the providers and contributes to injured worker animosity, mistrust and feeling treated like an object in the system. The physician conveys to the patient that he can't do what he wants to do to treat him. The patient is anxious because he can't do what his doctor said because the adjusters have said they are not going to authorize it until all of this documentation is produced. All the while, time elapses. Before you know it, we're getting into what I described earlier in terms of the identity transition from productive to disabled because the patient is being referred from one doctor to another.
Let's not continue to make the patient keep going through these hoops. It's disturbing when a patient says he or she has seen seven doctors and is feeling like a "jumping bean." And there is something about connecting with the doctor and staying with him in terms of comfort level and satisfaction. It is important for a patient to connect with their doctor and stay with him or her as much as is possible.
Lastly, another major advantage of utilizing SelectNet providers is that they all have experience and understand Worker's Compensation. This is crucial for effectiveness in managing and treating a multi-factorial symptom complex.
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