A focus for psychologists to consider in professional development is that psychologists are especially trained to help individuals with making lifestyle changes and adaptations.  Certainly, when an individual becomes disabled and injured this is an area for major lifestyle change and focus.  Depending on an individual’s disability and level of disability, the adjustments that a person needs to make not only to accommodate their disability, but as well as the necessary lifestyle changes, are areas for a psychologist to help transition the individual.  When an individual is disabled and has to make necessary changes to deal with the limitations that are imposed by the disability, there is a major adjustment.  This is where psychological principals can be implemented to assist a person in the necessary adjustments. 

        As psychologists we have expertise in training and in reporting, as well as in writing.  The Workers’ Compensation System as it now exists in the United States is a medical/legal system, which requires not only the understanding of medical practice and procedures, but incorporation of the laws and regulations as they currently are applicable from the labor code.  A psychologist who chooses to practice in this area must, in addition to staying current on medical practices, be current in the legal changes as they continue to evolve.

        Psychologists in particular have to focus on issues of self-esteem, change, disability, limitations, and dealing with a cumbersome medical/legal system which causes individuals to assess their personal identity and redefine themselves as an individual.  Social change is necessary since the changes have created a different social environment.  This requires an individual to be flexible in making new and productive relationships, as well as changes in friendships.  Part of the self-esteem that has to be adjusted is the financial change that often times is a result of limitations caused by one’s physical changes.  Self-esteem is effected by hobbies which one can no longer participate in, and that it may be necessary for new hobbies. 

       One of the most difficult types of life changes is that of unemployment and becoming re-employed.  Most often when an individual is no longer able to function and be productive in a work environment, they need to reestablish and become re-employed in work that they are capable of physically performing.  This causes significant stress.  The other factor regarding re-employment is that starting a new job or reentering the job market limits future productivity.  That may require someone having to adjust their lifestyle and their standard of living to accommodate their financial change.  In addition, part of the changes of self-esteem is that the intensity and level of relationships not only at work, but personal, are effected and may severely effect the person’s overall self-esteem.

       As a psychologist our fundamental work is to help people address their human needs.  The primary one is that of happiness.  Certainly when an individual makes major lifestyle changes their ability to maintain their happiness is challenged.  In addition, we tend to feel and be at our best when we are productive.  Most individuals who become limited by disability experience changes in their productivity.  We all appreciate the fact that we can participate in purposeful activities where we feel personal rewards and accomplishments.  Sometimes learning to have a functional relationship with work and in personal endeavors is fundamental to our individual survivability.  As a psychologist in the Workers’ Compensation System it is important to help with functional restoration to assist an individual to restore enjoyment, fun, and increased energy.

        As a psychologist one of the areas that we can use our training to excel is that of chronic pain management.  It is a clinical decision to recognize chronicity or the persistence of pain when, 1) the condition is not improving over time; 2) it fails to improve with treatment directed to the specific injured body part; and 3) in the absence of specific correctible autonomic lesions.  Often it takes a number of months for the clinician to recognize when pain becomes chronic.  In the treatment of chronic pain we underscore the shortcomings of the traditional bio-medical model and suggest a bio-psycho-social model.  This reinforces the role of “confounding psycho-social variables” in transition from acute to chronic pain.  It supports early identification and multi-disciplinary treatment of those at risk.

       Needless disability is secondary to chronic pain and is predictable and preventable.  Current standards of care find that evidence based treatments are the most effective.  A functional restoration approach to the management of chronic pain is a necessity for effective pain management.  The bio-medical model explains pain through etiologic factors, examples would be injuries or diseases whose physiological result contains the old cause and effect model.  The classic bio-medical approach to understanding and treating pain is incomplete.  Its exclusive application can result in unrealistic expectations on the part of the physician and patient, inadequate pain relief, excessive disability in those with pain that persists well after the original injury has healed, and unnecessary preventable chronic pain syndrome. 

        The bio-psycho-social model recognizes that pain is ultimately the result of pathio-physiology, psychological state, cultural background belief system, and a relationship-interaction with the environment.  The environment, of course, being workplace, home, disability system, and health care providers. 

       An effective functional restoration approach involves multi-disciplinary, individualized, educational, and is functionally oriented.  Focus should be not on pain oriented behavior, but to re-engage in home and work activities.  The locus of control shifts to the individual.  In a functional restoration program a multiple treatment modality involves pharmacologic, interventional, psycho-social behavioral, cognitive, and physical-occupational therapy.  Often times when a person has delayed recovery it is caused by distress, depression, anxiety, and low self-esteem.  Individuals who have excessive pain behaviors may show functional decline.  High pain ratings usually indicate and are managed by drug dependency.  A delayed recovery symptom is noted by disability out of proportion to the actual physical impairment. 

       Individuals with delayed recovery have a fear avoidance and maladaptive beliefs.  Many have a focus on the litigation and the resolution of a long-standing legal case.  Individuals with personality characteristics of somatization increase delayed recovery.  Delayed recovery can be the result of job dissatisfaction and prolonged work absence.  Recent research has found that delayed recovery has some basis from psycho-social risk factors such as childhood abuse.  Again this points to the realization that a psychologist can be the best professional to work with individuals who are not improving from chronic pain. 

       The chronic pain medical treatment guidelines focus on a functional restoration treatment plan which has therapies focused on functional restoration rather than merely the elimination of pain.  Assessment of treatment efficacy is accomplished by functional improvement.  When an individual begins to see themselves as changing their behavior and improving then their overall pain is significantly reduced.  Injured workers who return to life activities including work, stabilize medically, and avoid iatrogenic complications.  In addition, employers avoid unnecessary costs and have able employees return to work to increase their productivity.  This is certainly a win/win situation. 

       A treatment goal is to provide each patient with education and a range of tools that can help them confidently and more effectively manage pain.  Treatment should focus on the person’s sense of emotional well-being and independence, and to help them improve relationships and return to self-sufficiency and a normal lifestyle.  Treatment goals should establish achievable goals that enable increased productivity and return the individual to some form of gainful employment.  Treatment goals should provide quality care that is cost effective and with acceptable guidelines.  Goals for a psychologist are about returning a person to a useful, happy, functional, and productive life despite having a chronic pain problem. 

        A Clinical Psychologist with medical psychology training can be highly effective in helping in the use of medication, and determine the benefit, cost, potential side effects, and other medical problems.  Partial rather than the full relief of pain, sleep loss, and other symptoms is a more realistic goal with using medication.  In addition, as a psychologist, helping a patient understand the cause and meaning of pain is very important.  Learning to live with chronic pain is the focus — not having a pain free lifestyle. 

       In addition, the locus control is within the person not as a result of factors outside of one self.  Not letting the disability or pain determine who you are is important.  Becoming a person with a manageable pain problem rather than a chronic pain patient is important.  The education should focus on preventing relapses or back sliding.

       Cognitive Behavior Therapy is the most effective form of intervention to change perception of emotional response to pain.  Cognitive restructuring, relaxation training, guided imagery, desensitization, and pacing are ways that a psychologist can assist a chronic pain patient.  In addition, psychologists need to help the promotion of self-management perspective for each individual person’s disability.  Basic communication skill training is a must to help an injured patient meet their needs. 

       When a person has a disability, there are issues that relate to dietary habits such as weight management, nutrition issues, and the use of self-medication such as tobacco, alcohol, and illicit substance use.  An integral part of functional restoration programs is physical and occupational therapy.  The individual must be involved in an active and functional program which involves improved body mechanics and in most cases spine stabilization.  It is important for a disabled person to be in a stretching and strengthening program which will support a person’s bodily functions.  Aerobic conditioning as well as aquatic therapy has been a fundamental part of treatment that I have supported in functional restoration. 

        Certainly, work hardening and self-directed fitness programs are necessary for an individual to return to gainful employment.  Currently in our society it is especially difficult for an injured worker to access and return to gainful employment.  It is necessary to review transferable skills and job strength so that a person can have a realistic opportunity in the open labor market.  A psychologist can help identify and deal directly with problems such as pain behavior, lack of job seeking skills, poor self-concept, unrealistic goals, return to work fears, and lack of motivation.  A psychologist can help an individual focus on staying busy and being functional. 

       In conclusion, while biologic mechanisms play a role in the perception of pain, it is important to recognize that psychological and environmental factors are important.  Recognition of these factors will allow the physician to better treat the injured patient, to identify the at risk patient, and referred the patient with delayed recovery and an impeding pain chronic pain condition to the appropriate resources. 

       In this area, as a psychologist, managing and directing the overall recovery is a fundamental task.  In conclusion, therapy for chronic pain ranges from single modality approaches for the straightforward patient to a comprehensive interdisciplinary care for the more challenging patient.  Therapeutic components such as pharmacological, interventional, psychological and physical, have been found to be the most effective when performed in an integrative functional restoration manner. 

       It is important that all therapies are focused on the goal of functional restoration rather than merely the elimination of pain.  Typically with increased function comes a perceived reduction in pain and increased perception of its control.  This ultimately leads to an improvement in the patient’s quality of life and a reduction of pain’s impact on the individual and society.  Certainly this can be an important and contributing factor for us as psychologists.

Making Workers’ Comp Work Conference – March 2010 – San Francisco, CA

Frank J. Lucchetti, Ed.D.

RETURNING HUMANITY TO THE CALIFORNIA WORKERS’ COMPENSATION SYSTEM

           An injury is one in which a person gets a physical trauma, or even psychological trauma.  After some rehabilitation and medical treatment, the person is recovered. After recovery an employee is able to fully function as he was prior to the injury.  If the injury is such that the person does not recover, an example is loss of limbs, or an injury which requires a medical procedure such as fusion or replacement, then the individual is going to have a permanent disability which requires a certain percentage of whole person impairment and a award based on an arbitrary scale which has been used almost a century. The ultimate question is, “is this employee going to be able to continue to function in the job which he was hired.”

           If we look at disability as being permanent then we have to begin to discuss what effect this disability has for an individual.  It is my belief that we all have disabilities.  The reality is that some of us understand that we are not the best golfers, fisherman, skydivers, or even maybe the best public speakers.  We have an acknowledgment of where our weaknesses are.  When a person has an industrial injury, they have an accumulation of new disabilities.  Some individuals are able to make an adjustment and are able to incorporate the new disability with their pre-existing limitations.  If they are able to do that well then the person becomes better functioning.  Many individuals after a new disability, decompensate to the point of where they are not functioning at any level and are highly dysfunctional.  These are the individuals that we are all most concerned with.  This is why we are at this conference.  These individuals are the ones who are the drain on the system, as well as in our society, because they are dysfunctional. 

           A disability or injury can either make a person stronger or in fact weaker.  In most cases, the ones that we are most involved with are individuals whose  self-esteem crumbles as a result of a new physical or emotional disability.  Their lowered self-esteem then affects their role in all parts of their life.  When an individual has an injury the effect on how it interplays with all the other members of one’s life is important.  If the individual can be a positive effect on the others then we have a functional recovery, but in most cases it is not functional, but rather dysfunctional.  The role of a disabled injured worker has a negative effect on all. 

           When a person becomes injured they have a change in their personal identity.  The life of a policeman or a fireman, who for twenty five or thirty years has been involved in his craft and has personal friends as well as familiar friends, once an individual is not able to perform as a fireman or policeman, then that individual’s identity is negatively impacted.  That individual must interact with the people in a different way.  Many individuals who are severely disabled have difficulty finding employment or re-employment.  Many employers, once an employee is severely disabled can no longer maintain the employment status.  The individual must find alternative or new employment in order to function and be happy.  The monetary reimbursement for their work is no longer the same as it was before they became physically injured.  What happens to people in our society now, whether it is due to a disability or as part of down-sizing restructuring, has become a standard in employment today.  When an individual loses their job either, through disability or reduction in force, they must become entrepreneurial and as part of their entrepreneurial spirit learn to be self-employed, or employed in the manner that they provide services in a limited and manageable manner.  A person must have some form of self-fulfillment in a hobby or interest, or skills that they are good at that can be turned into a marketable productive services which others find necessary and are willing to compensate them.

           Recovery from disability involves a team approach.  Most beneficial recovery and quickest form of recovery is one which has a supportive environment which includes the injured worker, the treating doctors, the insurance company, the lawyers and representatives from insurance companies as well as re-employment agencies.  If a team approach can be established and all of the individuals are supportive in meeting the goals of re-employment for the injured worker, then a return to active and productive status is highly effective and immediate.  This is where my topic of “Returning Humanity to the Worker’s Compensation System” is important.  We agree that a healthy individual who feels that he is in control of his destiny and his life, will help return the Worker’s Compensation system as a functional system.  If a system supports dysfunctional individuals then the system is dysfunctional.  In all cases where a person becomes significantly disabled a mental health person with the understanding of the psychological factors as well as the medical/legal factors that are involved in this system is an important and integral part in the successful rehabilitation of an injured worker. 

           A mental health provider can help an injured worker regain a positive affirmation about themselves and who they are, and set some goals for themselves and their future.  Most workers who have an injury and go through the Workers’ Compensation System come out feeling like a victim.  That is an individual who doesn’t feel empowered and who feels that no matter what he does they won’t be successful.  Having an individual be a victim is not good for anyone. 

           A mental health person can help control and manage pain.  Obviously, without a brain you don’t have pain.  A fundamental concept is that if an individual’s way of thinking and reacting to discomfort can be improved or helped, then the individual will have less requirements for opiates, muscle relaxants, anti-depressants, anti-anxiety medications, and sleep medications.  All of these medications makes it difficult to be at your best as a human being. 

           The other strategy is that a mental health person can help with understanding the need for medical treatment and the various medical sub-specialties.  Most people do not understand the different medical specialties.  Examples are neurologists, orthopedists, internists, cardiologists, psychiatrists – all of these titles are confusing to an individual who doesn’t have the medical sophistication and understanding of the different specialties.  In addition, when doctors discuss medical treatment and or medication, they often do that in a very quick and abrupt manner.  As we realize surgeons do not have the best communication skills.  That’s not what we pay them to do, communicate, we pay them to do surgery.  They are highly paid and effective technicians.  As far as helping an injured worker feel comfortable and understanding of what any procedure is going to do for them, or what the medication is going to accomplish is difficult.  Most often the patient just goes along, often feeling like a victim and not understanding what the course of treatment will be. 

           A mental health provider can help an injured worker remain functional and deal with the stresses of everyday life, such as financial issues, inter-relationships, daily routines and activities.  All of which are highly impacted by an injury, especially a disabling one, especially when a person is in recovery either from surgery or from a crippling injury.  Helping an individual to manage life stresses which naturally occur and are part of living in a society such as ours is an important role for a mental health professional.

           Helping an individual regain ego strength and having a better self-esteem is necessary.  Ego is having to deal with self and one’s opinion of self.  For an individual to one day become disabled, not be able to provide for themselves, and their families, their sense of worth is diminished as well as their sense of purpose in life.  There is no reasons for an individual to live and to prosper if they don’t believe they are going to improve or do better in life.  Such is the case for all humans and definitely an important factor for an injured worker.  When a person becomes disabled or injured their relationships suffer, both personal relationships and business relationships.  There must be changes in the types of activities as well as the adjustments in how a disabled injured worker participates in such activities.  It is important for all of us to understand that humans have a hard time with change.  We all are creatures of habit.  When we are asked to change or do things we are not accustomed to doing we become stressed and anxious.  This is a normal part of human change.  When you combine that with a disability as well as post-surgical conditions, you can understand why many injured workers have difficulties in making the necessary adjustments and changes to become productive.

           From a psychologist’s point of view, we need to manage pain. We have two known ways to manage pain.  One is to medicate and use pharmaceuticals.  The other is lifestyle changes which can minimize the level of pain.  It is common to see medical doctors who are trained anesthesiologists use a cornucopia of medications from narcotics, to muscle relaxants, to sleep medications, to anti-depressants, to high blood pressure medication, all of which are intended to help stabilize an individual’s mental and physical conditioning.  Every action has a reaction, which is a law of science.  When an individual takes a medication there are side effects.  Many medications which are necessary to lower pain are strong medications and have a great effect on mental acuity and functioning.  Not only do they effect the cerebral frontal cortex which involves judgment and memory, but they also effect the limbic part of the brain, which has to do with emotion.  As such, individuals who are in pain have emotional flare-ups which are caused not just by the pain, but also from side effects of the pharmaceuticals.  Additionally, pain can be minimized by medical procedures, such as fusion, such as arthroscopic surgeries, and of course injections.  These are common medical accepted standards for relieving the most critical and crippling forms of pain. 

           Surgeons perform procedures which are necessary to allow the person to function.  These can include prosthesis, replacement of arthritic, or destroyed bones, muscles and tissues.  Surgeries can replace parts which are no longer functioning such as hearts, kidneys, and even faces.  We have not yet perfected a brain transplant, but possibly in the future that is going to happen as well.  These are all ways that Western medical science has used to help improve the human condition.  We have what is considered alternative medicine – those include things such as acupuncture, physical therapy, massage, hydrotherapy, chiropractic care, meditation, and hypnosis.  These when appropriately used can provide significant lifestyle improvements and changes which allows an individual to be productive.  If we use a scale of 0 – 10, where 0 is no pain and 10 is the most intense pain that one can imagine, human beings can survive and be able to function with pain levels and 1 – 3.  Between 3 and 7 it is difficult to concentrate, to not have emotional distress and physical energy.  When an individual’s pain is an 8 or a 9 functioning at any level is impossible. 

           One factor that is important to understand in managing pain is that a lifestyle change is often required.  If pain is an everyday factor for an individual then doing different activities, limiting activities or pacing the type of activities that one does can be significantly helpful in improving the level of pain that one suffers. When all of these factors are used in combination then the individual can thrive and be a happy and productive person. 

          What happened in 2009 regarding accommodation and return to work was that in the area of disability discrimination the ADA, Federal Test was strict, and the FEHA State test was broad.   The ADA was directed not to discriminate, that there be reasonable accommodations made, and that there be no retaliation.  Likewise for FEHA, with the additional requirements to prevent discrimination, and to engage in good faith interactive processes.

 Questions that need to be asked are:

Is there a disability and how is it measured (Injury AOE COE/Medical certification)

When does the good faith interactive process start?  (Effect of termination or other adverse action under L.C. sec. 132a)

What is a reasonable accommodation?  (Effect on PD, failure to process claim timely, potential 132a)

 2009 Developments in the area of ADA amended, GINA, FMLA Regs amended regarding medical certification, notice, comparison at Http://www.fehc.ca.gov/pdf/FMLA-CFRARegsTable-2.pdf

 ADA AMENDED (ADAAA) includes ignored disabilities and disability in remission, expanded definition of major life activities, deletes mitigating measures other than ordinary eyeglasses/contacts, and required EEOC to revise definition of “substantially” limits

http://www.fehc.ca.gov/pdf/ADA-ADAAA-FEHA_Table-2.pdf

When a medical certification issue is involved in an injured employee’s return to work the amended FMLA Regulations allow the employer to contact the medical provider (not supervisor), the employer can designate what info is needed from the doctor, and may ask the doctor to review the job description.  The employee must follow employer’s regular notice procedures.

 Can an employer reject the treating physician’s opinion?  What is the difference between work comp and disability discrimination? Under comp law, there is no discrimination as long as all disabled individuals get evaluated under the same circumstances. Under ADA, separate evaluation may be medical examination and must be narrowly tailored to job duties – consistent with business necessity

 There is no discrimination under 132a for rejecting treating physician’s opinion as long as the Risk Manager followed up with the treating doctor who admitted, there is an evaluation by AME, and an ok to return to work.  Standard under Lauher – must have different treatment based on the industrial nature of his injury, not some negative consequence as a result of an industrial injury. Gelson’s Markets, Inc., v. WCAB (2009) 179 Cal.App. 4th 201

Possible discrimination under ADA for employer required evaluation.  If Medical Examination post hire, court will carefully scrutinize and must be job related and consistent with business necessity.  Physical agility tests are not considered medical examination – just merely observations.

 Medical exam means: invasive tests, use of medical equipment, in medical setting, administered and performed by professional, whether the test measures an employee’s performance of a task or measures his/her physiological responses to performing the task and finally, test could reveal impairments of physical or mental health (inquiry into history/family history).

 What is a reasonable accommodation? One must consider an employer’s failure to consider mean and possible increase in payment in Work Comp liability in court case.

Employer’s obligation to accommodate is continuing.   Once the final accommodation is determined, the employee does not have to continue to engage in a good faith interactive process.  A one time inadvertent failure to accommodate will result in liability even if the employer has a record of past accommodation.