Winter 1997, Vol. 6, No. 2

Disabled workers: Personality, organizational and treatment factors

By Don Williams, M.D., CGP

The aim of this paper is to describe an approach to the treatment of patients with workplace injuries that includes individual psychotherapy, group psychotherapy, and pharmacotherapy. The interplay of Axis II disorders with depression, anxiety, and pain, and their implications with regard to prognosis and treatment by means of group therapy will be addressed. Our third aim is to provide a brief overview of those systemic and organizational factors that promote health and prevent disability; those that promote recovery if an injury is sustained; and those which promote disability and retard recovery.¹

Workplace injuries exact a huge economic burden in our society. In 1992 compensation costs, treatment costs, and other indirect costs amounted to $171 billion, including direct costs of $65 billion and indirect costs of $106 billion.² Injuries cost $145 billion and illnesses $26 billion. Low back pain alone was calculated to cost $26.8 to $56 billion in medical care, compensation payments, and time lost from work. The 5 percent who become chronically disabled incur 90 percent of these costs.³

A treatment model similar to that used for soldiers injured in wartime has been employed for the psychiatric treatment of injured workers. Wartime military practice emphasizes a highly structured, non-analytic approach with an emphasis on a rapid return to the combat military unit. In the case of injured workers, the emphasis has been shifted to focus on a rapid return-to-work (RTW). Underpinning this approach is wartime experience: soldiers with a post-traumatic stress disorder who were not returned to their units quickly tended to develop full-blown and disabling chronic conditions resistant to conventional therapeutic efforts, depriving combat military units of manpower.

Clinicians and organizations involved in the assessment and treatment of patients who experience workplace injuries frequently employ this military-derived model. The stated goal is a rapid return to the workplace. Action-oriented medical interventions and physical therapy, accompanied by admonitions to "learn to live with the pain" are commonplace.

However, biases on the part of physicians may lead to incomplete evaluations, missed diagnoses, and treatment failures.^{4 5} The false belief that psychological problems and psychiatric disorders are the primary cause of chronic pain syndromes may cause doctors and claims administrators to label patients as neurotic or malingering. In fact, chronic pain more often precedes depression, and causes social and psychological problems.⁶ Another false belief is that receipt of compensation and retention of a lawyer reduces the likelihood of RTW.⁷ In fact, prospective studies fail to demonstrate any predictive power regarding future employment status.

A third false belief is that receipt of compensation will prevent an RTW.

Both prospective and retrospective studies contradict this assumption.^{8, 9}

The interplay between pre-existing personality disorders and workplace injuries is complex. Disputes regarding whether the workplace injury or the preexisting personality disorder is responsible for maintaining ongoing disability are commonplace. One side asserts that the personality disorder sustains the disability, while the other maintains that "but for the injury" the worker would still be working. In one respect, both sides are correct. The process can be more accurately understood as one in which the fragile sublimatory outlets for aggression are disrupted by the injury, disrupting the fragile ecology of the individual, disturbing his relationships with family, friends, coworkers, and society.^{10, 11}

Popular notions regarding the prevalence of fraud appear to be inaccurate as well. Recent statistics published on the Internet by the responsible state agencies regarding fraudulent claims by workers reveal incidence rates that are remarkably low.¹² For 1992-94, of 9,000 completed investigations, there were less than 150 guilty findings, a rate of under 2 percent (of actual investigations, not of total claims). Investigation costs are not low however; using budget figures and case activity data compiled for eight states, each guilty finding cost $117,000.¹³

These prejudices are not new. In 1893 Freud observed of Charcot, "In the first half of the eighties, …he succeeded in proving the presence of regularity and law where the inadequate or half-hearted clinical observations of other people saw only malingering or a puzzling lack of conformity to rule.

"Let us suppose that a heavy billet of wood falls on a workman's shoulder. The blow knocks him down…. After a few weeks, or after some months, he wakes up one morning and notices that the arm that was subjected to the trauma is hanging down limp and paralyzed…" Freud then proceeds to elaborate his theory of psychical trauma, and the hysterical symptoms which result. Prior to Charcot, hysteria was deemed unworthy of study because it was viewed simply as malingering.

Both administrative and professional cultures interfere with effective evaluation and treatment. In the administrative realm unsophisticated or narrow conceptions regarding cost containment, cost shifting to the social security disability system or other public agencies, and a need to show cost cutting results for the immediate reporting period may lead to a denial or delay of treatment and diagnostic authorization. In the medical realm, psychiatric abnormalities that are the normal response to chronic pain may cause physician withdrawal, disinterest, and hostility. A lack of familiarity with alternative treatment models with demonstrated efficacy might result in a failure to employ the most effective methods. Insurer behavior may also contribute to poor outcomes; necessary diagnostic studies are often delayed, or denied. Physicians may choose not to order needed studies because of the administrative conflict and inconvenience associated with such requests.

This comes at a price. Rehabilitation by comprehensive multi-disciplinary teams yielded an RTW average of 54 percent to 85 percent, depending on patient selection, compared to less than 30 percent of chronic patients receiving conventional treatment.¹⁴ Referral delays for comprehensive treatment for back pain patients have been shown to increase direct costs¹⁵ from $15,000 to $50,000.

Complexity must be recognized. "The first step in making a diagnosis is to think of it. Discarding discordant data, trying too hard to make a favored diagnosis fit, and refusing to let go of the assigned diagnoses are all diagnostic traps in which even a seasoned clinician can tumble."¹⁶ Reading an elegant paper on "Clinical Problem Solving" by George E. Thibault, the reader's attention is captured by the drama and tension associated with a rapidly developing medical crisis. That it concludes with the death of the patient because of a failure in the diagnostic process lends urgency to the principles that it highlights.

Similar crises of conceptualization and problem solving exist in psychiatry, but they often elude notice. Perhaps that occurs in part because the time scale by which we practice is elongated; rarely do we have a drama like Thibault's, with a failure to accurately appraise a clinical problem leading so quickly to a fatal outcome. Our failures occur in slow motion, and are more easily ignored. It is easier to ignore or overlook poor outcomes when they occur without fanfare. A fatalistic attitude that such outcomes are to be expected given such a condition or that kind of patient is easier to sustain. Such pseudoexplanations may prevent clinicians from subjecting the underlying assumptions on which they are based to appropriate critical scrutiny.

A sense of history is valuable. The example of hysteria is cited above, and others followed. Before John Cade and Morgan Schou discovered the effectiveness of Lithium in the treatment of bipolar mood disorder, manic-depressives were generally considered untreatable. It was only in 1970 that the FDA approved Lithium for the treatment of mania. Prior to the work of Mahler, Winnicott, Masterson, Kohut and others in the mid-1970s, patients with borderline and narcissistic disorders were rarely treated effectively; they simply were not understood. It was not until 1980 that the persistence of ADD into adulthood was generally recognized, and that emphasis began to be placed on attentional deficits. Only in the past ten years has the importance of comorbid disorders and combination therapy been generally appreciated.¹⁷ Ten years ago no effective treatment was available for Obsessive Compulsive Disorder.

In each of these examples, progress resulted from advances in neurobiology, a better understanding of psychological developmental issues, or both. Careful clinical observation and the systematic testing of hypotheses and the corroboration of findings by independent observers led to further conceptual refinements of theory and practice, and therefore to more effective treatment.

My thesis is that injured workers with their psychiatric problems are in the same boat that their Hysteric, Bipolar, OCD, Borderline, and ADHD predecessors were 100, 25, 15, and 5 years ago; poorly understood by most clinicians today, they often receive little or no treatment or ineffective treatment when they are referred. Their treatment failures occur in slow time. There is a disconcertingly familiar (to psychiatry) tendency to speak and act disparagingly towards these patients. They are often evaluated and treated by psychiatrists who lack experience in approaching their complex problems with a biopsychosocial model. With the decline in psychotherapy training in most current residency training programs, many new psychiatrists lack the knowledge and requisite experience dealing with transference and countertransference phenomena to function effectively with these challenging patients, either in an evaluation or in a treatment mode.

Treatment Factors

I propose a theoretical approach to treatment that encompasses an awareness of diagnostic, developmental and psychodynamic issues.

Patients with workplace injuries may develop psychiatric disorders as a result of the traumatic losses associated with injuries on the job.¹⁸ These conditions include Major Depressive Disorders, Panic Disorders with or without Agoraphobia, and Pain Disorders. Injuries and the losses that follow in their wake often bring pre-existing personality disorders to light or aggravate those already in evidence.

A solitary emphasis on the immediate return-to-work with suppression of all feelings of loss, anger, and grief regarding the trauma of the injury is more likely than not to yield poor clinical results. A bio-psychosocial approach should be utilized to take into account the particular circumstances and opportunities presented by patients with workplace injuries. Injured workers carry multiple psychiatric diagnoses as a rule, with depression present in nearly all patients and Axis II conditions present in three fourths of cases referred for treatment. Anxiety, pain, and substance abuse disorders are other commonly encountered comorbid conditions requiring specific treatment.

The psychiatric clinician treating injured workers becomes aware of certain features common to such patients. Mild to Severe Major Depression is present in most, if not all of those referred for psychiatric evaluation. The injured worker in this referral population typically develops major depressive symptoms between eight and fourteen months after the date of the industrial injury. This depression results from a multiplicity of causes including: loss of role status, both in the family and in the community; loss of self-esteem based on the increasingly apparent disparity between the damaged real self and the internalized pre-injury self-representation; chronic pain; loss of hope of recovery; activation of intrapsychic negative self-representations previously compensated for through having established a successful work role identity; and inability to re-establish their fragile early sublimations for the expression of aggression.

Panic and other anxiety disorders occur more frequently in injured workers describing abuse and neglect in their developmental histories. However, an intensification of symptoms often occurs in concert with the social withdrawal that frequently accompanies disabling injuries. Agoraphobic symptoms in particular have a tendency to become more prominent.

Pain disorders (when not the result of missed physical diagnoses) are almost invariably associated with depressive illness. Patients who have difficulty putting feelings into words complain more of pain. Patients who have a highly developed capacity to symbolize affects may experience pain in equal amounts, but they devote less attention to it and are less preoccupied with pain than their less-verbal counterparts.

Personality Factors

Group psychotherapy¹⁹ is a treatment model that offers a clinically specific and cost-effective response to patients injured in the workplace. The nature and severity of the patient's psychiatric condition determines session frequency.

Group psychotherapy can be effective in enhancing the treatment of personality disordered patients, whatever their comorbid Axis I diagnoses may be.²⁰ It allows for the use of peer pressure and confrontation, with specific and concrete learning opportunities making the patient aware of the impact his socially dissonant conflicts have on other members of the group.²¹ As Alonso and Rutan point out, "The patient must internalize and introject new realities, including an internalization of the current relationships in the current maturational environment. This must occur over and over again in order for the process of working through to take place. Through working through, the patient is able to combine insight and internalization and to transform old character traits to new." In a particularly illuminating observation, they comment, "The big difference between working in a group versus working in a more controlled dyadic environment is that the group patient is in a position to immediately have the problems in the group that bedevil his or her life outside their group." This leads to a therapeutic and creative interchange among members of the group, which, over time, facilitates new and healthier introjections and internalizations. This is of major value in the workplace and in the family.

Group therapy alone, with appropriate pharmacotherapy for depression, or anxiety disorders, can be particularly effective with this patient population. Group therapy offers an approach that can accelerate treatment with a wide spectrum of patients, including those who would be unlikely to benefit from traditional individual psychotherapy, whether psychodynamic or cognitive in nature.

"Some medical patients have difficulty in experiencing and expressing their feelings directly and often express their feelings somatically. Because of that affective style, those somatasizing patients often have trouble in establishing a relationship in individual psychotherapy or become regressed and overdependent on the therapist. Group therapy is often more effective than individual therapy for somatasizing patients because the group provides an opportunity for multiple transferences."²²

Borderline patients with life-threatening behavior may need to be seen daily as an alternative to inpatient hospitalization; this is cost-effective and therapeutically advantageous because of its tendency to be less productive of regression. The group therapy sessions can be increased or decreased in frequency as the patient's condition dictates, from one to five times per week. Since the groups are comprised of different members there is less likelihood of regressive dependency developing. Continued functioning is required, with the patient being encouraged to talk through intense feelings rather than act them out.

Once or twice weekly individual therapy sessions may be necessary to enable some patients to tolerate the group work. This may arise when issues involving intense shame and embarrassment need to be partially detoxified in an individual setting prior to being dealt with in the group. For example, an initial revelation of compulsive self-mutilation is often possible only in an individual setting, because of the often-overwhelming affect accompanying the behavior and its meaning. It can likewise be destructive to healthy group functioning if the time and attention needs of one member are so great that they lead to that person's monopolizing the group's time for an extended period.

Substance abuse coexists frequently with affective, anxiety and personality disorders.²³ Vigorous multimodality treatment interventions may be required, including separate inpatient or outpatient substance abuse treatment and combination pharmacotherapy targeted to the coexisting Axis I diagnoses. These patients are demanding and difficult clinical challenges. Patient non-compliance is a major cause of poor treatment outcome, contributing to their poor prognosis. Private clinicians might consider referring these high-risk patients to institutional settings to diminish the likelihood of splitting treatment efforts.

Patients with solitary diagnoses of Major Depression, Pain Disorder, or these diagnoses in tandem can often be treated effectively with a combination of group therapy and pharmacotherapy, requiring little or no individual therapy. This decision should be made on a case-by-case basis.

Organizational Factors

Workplace injuries occur within the context of business, social, and governmental structures and cultures. A reciprocally interactive relationship exists between the injured worker, his injury claim, and these institutions. The worker's personality structure, biological predisposition, and adult developmental stage all play an important role in influencing the course of the illness. The business structure, business culture, business developmental stage, and attitude towards workers with problems likewise influence the course of the worker's illness and recovery. Court precedents, administrative practices, and other third party influences also impact the process. Furthermore, these systemic influences bear upon the treating psychiatrist, who may experience economic, political, or other pressures influencing or even determining his treatment practices. An awareness of these interrelationships is essential to an effective multidimensional appreciation of the ecology of the workers' compensation patient and the processes with which he contends.²⁴

Study Results

One hundred nineteen consecutive patients with workplace injuries being treated or who have completed psychiatric treatment in a private psychiatric practice are described. The average age was 46, with a range of 22-64 and a standard deviation of 10 years. Of these, 45 (38 percent) were female and 74 (62 percent) were male. Sixteen patients (2 female and 14 male) continued to actively abuse alcohol or drugs, and were dropped from treatment because of their unwillingness to enter substance abuse treatment. None of this group returned to work. Of the remaining 103 patients, 38 returned to work, 17 continue in a transitional state with a reasonable likelihood of returning to work, 7 have retired with state pensions because of the severity of their injuries, 37 failed to return-to-work, and 4 have unknown outcomes. Return-to-work is defined as having successfully completed a meaningful training program, or having returned to work in a capacity that was meaningful and satisfactory to the patient. The duration of treatment for patients who have successfully returned to work ranges from 0 months (patients that were working at the beginning of treatment) to 5 years. Ages of successful RTW patients ranged from 24 through 61 (mean=41, SD=9). The ages of unsuccessful RTW patients ranged from 28 through 64 (mean=48, SD=10). Unsuccessful RTW patients had a higher frequency of more severe Axis 2 diagnoses (borderline, schizoid, avoidant and antisocial) and panic disorder as the primary Axis 1 diagnosis in addition to depression. All patients had attorneys to represent them in their workers' compensation claims. Youth, intelligence, higher educational attainment, an absence of childhood abuse, and higher status jobs were favorable but not finally determining factors. Even some apparently unlikely patients successfully returned to work, sometimes with the assistance of lengthy and intensive group and individual psychotherapy. These statistics, i.e. a 37 percent RTW rate with an additional 15 percent likely to return-to-work, compare favorably with some published reports of RTW success rates (20 percent in one integrated program that treated patients that had been out of work an average of 4.9 years).²⁵ Other programs have reported higher RTW rates, but they have dealt with carefully selected populations, and were comprised of patients whose time off from work has been considerably less. It may be that developing a flexible and intensive group therapy treatment modality for personality disordered patients in combination with a meticulous approach to the pharmacological treatment of comorbid Axis 1 disorders contributed to the successful treatment of some patients. This hypothesis will need to be confirmed by other clinicians.

Successful treatment does not always mean return-to-work; either the physical injuries may be too severe, or the internal resources of the patient may not be sufficient. Sometimes symptom reduction and suicide prevention represent the limits of what can be accomplished clinically given currently available treatment strategies. Additional study of the data obtained in this patient sample may yield more refined approaches to determining prognosis and the most effective treatment approach, if indeed treatment is indicated. It should also be stated that future advances in technique and knowledge will yield further improvements in RTW percentages.

References

¹ Between 1994 and 1996 Continental Airlines acquired a new management and a new mission, with the following results: Workers' Compensation claims decreased by 45%. Sick leave is down 16%. In the 1996 Annual Report, CEO Gordon Bethune stated: "We are Working Together. It is the major difference between a dysfunctional airline with January 1995 market value of $175 million and the 'Airline of the Year' with a market value nearing $2 billion that we are today. We must always treat each other with dignity and respect, pull our weight, do our jobs and behave fairly."

² Leigh, J. P. et al., "Occupational injury and illness in the United States," Arch Intern Med. 1997;157:1557-1568

³ Gallagher, Rollin M., "Referral delay in back pain patients on workers' compensation," Psychosomatics 1996: 37:270-284.

⁴ Hendler, N. L., and Kozikowski, J. G., "Overlooked physical diagnoses in chronic pain patients involved in litigation," Psychosomatics 1993: 34:494-501.

⁵ Hendler, N. L., et al., "Overlooked physical diagnoses in chronic pain patients involved in litigation, Part 2," Psychosomatics 1996; 37:509-517.

⁶ Williams, C. D., "Group psychotherapy in the treatment of injured workers," paper presentation, 1997 APA Annual Meeting.

⁷ Gallagher, R. M., et al., "Workers' compensation and return-to-work in low back pain," Pain: 1995: 61:299-307.

⁸ Ibid.

⁹ Dworkin, R.H., et al., "Unraveling the effects of compensation, litigation, and employment on treatment response to chronic pain," Pain, 1985 23:49-59.

¹⁰ Personal Communication, Anne Alonso, Director, The Center for Psychoanalytic Studies, Harvard Medical School, Massachusetts General Hospital.

^11,12 Personal Communication, Charles Mangham, Supervising and Training Analyst, Seattle Institute for Psychoanalysis, and Clinical Professor, University of Washington Department of Psychiatry

¹³ State Workers' Compensation Anti-Fraud Activity: Survey Results, Minnesota Department of Labor and Industry, 1995 (This is a compilation of a national survey)

¹⁴ Ibid.

¹⁵ Mayer, T.G., et al., "A prospective 2-year study of functional restoration in industrial low back pain." JAMA, 1987; 258:1763-68.

¹⁶ Gallagher, R.M. (1996)

¹⁷ Thibault, G.E., "Clinical problem solving: failure to resolve a diagnostic inconsistency." N Engl J Med: 1992; 327-36-39.

¹⁸ Oldham, J. M., et. al., "Comorbidity of Axis I and Axis II disorders," Am J Psychiatry 152:4, pp. 571-578, 1995.

¹⁹ Grant, B.L. and Robbins, D.B., "Disability, Workers' Compensation, and Fitness for Duty," Mental Health in the Workplace: A Practical Psychiatric Guide, Kahn, J.P. ed., Van Nostrand Reinhold, New York, 1993.

²⁰ Porter, Kenneth M.D. "Combined Individual and Group Psychotherapy," pp. 314-324, Comprehensive Group Psychotherapy, Kaplan and Sadock, Eds, Third Ed., Baltimore, Williams and Wilkins, 1993.

²¹ Alonso, A. and Rutan, J., "Character Change in Group Psychotherapy," Int. J. Group Psychother. 1993; 43(4): 439-451.

²² Azima, F. "Group Psychotherapy with Personality Disorders," pp. 393-406, Comprehensive Group Psychotherapy, Kaplan and Sadock, Eds, Third Ed., Baltimore, Williams and Wilkins, 1993.

²³ Ulman, Kathleen H. "Group Psychotherapy with the Medically Ill," pp. 459-470, Comprehensive Group Psychotherapy, Kaplan and Sadock, Eds, Third Ed., Baltimore, Williams and Wilkins, 1993.

²⁴ Jaffe, J. H., "Opioid-related disorders," p. 843, Comprehensive Textbook of Psychiatry, Kaplan and Sadock, Eds, Sixth Ed., Baltimore, Williams and Wilkins, 1995.

²⁵ Chart: "Clinical Evaluation and Treatment of Disability at the Individual and Organizational Level" Williams, C.D., 1997.

²⁶ Hendler NH: Validating and treating the complaint of chronic back pain: The Manassa Clinic Approach, in Clinical Neurosurgery, Baltimore, B.P. ed., William and Wilkins, 1989, pp.385-397.

 
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