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.

 

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