Scott Bevis Clinical Psychologist Dynamic Minds Psychology Resilient Tomorrow TIO Conference October 2014 Overview The problem at hand Work injury amp the biopsychosocial model ID: 273830
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Slide1
Early Psychological Intervention with Physically Injured Workers
Scott Bevis Clinical PsychologistDynamic Minds Psychology
‘Resilient Tomorrow’
TIO
Conference
October 2014Slide2
Overview
The problem at handWork injury & the biopsychosocial modelRisk factors for poor outcomesEarly psychological intervention Barriers to early interventionSlide3
The Problem at Hand
The longer a person is absent from work due to illness or injury, the lower their chance of ever returning to employment (AFOEM, 2012) The longer an employee remains in a worker’s compensation system, the poorer their return to work and health outcomes will be
(Konekt, 2013)
Chronic pain is Australia’s 3
rd
most costly health condition with an estimated economic
cost
in
2007
of $34 Billion
(Access Economics, 2007)Slide4
The Chances of Returning to Work
Time off work
(AFOEM, 2012) Slide5
Return to Work Rates at 7-9 months
The social research centre, 2013Slide6
The chances of returning to work
Time off work
AFOEM Position statement 2012 Slide7
Contributors to
the problem Adherence to the medical model
Individuals..... we are all unique
Compensation systems
The neurophysiology of painSlide8
The Medical Model
Core assumptionsThere is a linear
relationship between
injury, symptoms & disability
That by treating the underlying pathology the patient will get better
Limitations
Neglects the significance of the personal & contextual dimensions of injury and recovery
Implicitly encourages
passive
recovery behaviour
Colludes with patients’ unhelpful ideas about pain & recovery
Treatment is escalated sequentially based on non-responsiveness
Slide9
The Uniqueness of People
Individuals bring along their own experienceThoughts, attitudes, & beliefs Feelings & emotions Actions & behaviours
As informed by;
Demographics, education, health literacy, personal & family history, personality & interpersonal style, etc. Slide10
Compensation & Recovery
The purpose of workers’ compensation insurance is to facilitate optimal recovery and return to work following injury
The compensation hypothesis - patients within compensation
systems have
worse
outcomes than
non-compensable
patients
The evidence is not conclusive
(Spearing et al, 2012)
Claimants do encounter additional factors
Dealing with the claims
and settlement
process
Exposure to medico-legal
assessments,
Perceived lack of trust about having to prove an injury or disability
.
The necessity
of legal
representation
Embitterment toward the system
strong sense of entitlement & injustice
An inability to move on with life during the claims process,
(
Mergatroyd
et al. ,2011)Slide11
Neuroplasticity & Chronic Pain
Pain lasting beyond the expected healing time for the damaged tissue (3-6 months)Has a distinct pathology separate to the catalysing injury
Associated with changes in the nervous system that continue to worsen
over
time
Contributes to ongoing decline in physical & psychological wellbeing
Poorly understood by patients (and treatment providers??)
Best treated via a multidisciplinary approach
(Pain Australia, 2014
;
US Institute of Medicine, 2011
)Slide12
Biopsychosocial ModelSlide13
Adoption of the BPS model
Now recognised & promoted by workers’ compensation authorities in Australia & NZ
The Clinical
Framework for the Delivery of Health
Services (Victorian WorkCover/TAC) *
The
NSW
WorkCover program
and
guidance
The
ACC Pain Management
Services
(NZ)
Nationally
Consistent
Approval Framework
for Workplace Rehabilitation
Providers (HWCA)*Slide14
Risk Factors for Poor Outcomes
In the context of work injury, there are numerous psychosocial factors that impact recoveryThese factors are often identifiable around the time of injury and if left unattended often become the maintaining factors
The
Flags
concept
was introduced as a framework
for
understanding and evaluating the personal and contextual elements as ‘risks factors’
Whilst not
diagnostic ‘Flags’ signal specific obstacles to recovery and indicate where extra attention is required
Provide a standardized language for dialogue about these features in everyday practice and between disciplines
(Kendall & Burton, 2009)
Slide15
Types of Flags
Red
Indicator
of serious biological pathology
Yellow
Beliefs,
thoughts and attitudes about injury and context
Emotional Responses to injury and context
Pain Behaviours (coping style, how
relate to injury)
Orange
Psychiatric
symptoms
Blue
Perception about the work
and injury relationship
Black
System and contextual
barriers Slide16
Flags in the BPS ModelSlide17
Psychosocial Risk Factors
Fear avoidance beliefs/behaviour
Catastrophic thinking
Stress & anxiety
Depressed mood
Low self efficacy
Passive coping styles
Depression (MDD)
Anxiety disorders
PTSD
Personality disorders
Perceived injustice
Inadequate support
Excessive demands
Low morale claims*
Toxic workplaces
Scope of RTW options
Legal orientation
Poor claims handling* Slide18
Yellow Flags
Fear avoidance beliefs/behaviour
Catastrophic thinking
Stress & anxiety
Depressed mood
Low self efficacy
Passive coping styles
(Nicholas et al, 2011)Slide19
Early Psychological Intervention
The risk factors for poor outcomes are known
These factors are identifiable at or around the time of injury
The aim of early psychological intervention is to;
Assess for the presence of psychosocial risk
factors, and when indicated
Address the risk factors to reduces the potential
for poor health and poor RTW outcomes Slide20
Early Psychological Intervention
Why psychologists?Experts in mental health Trained & experienced in the BPS model, psychological assessment and relevant evidenced based treatments
Understand the significance of normal risk factors and capable of discriminating between the flags
Why early?
Address psychosocial factors acutely or sub acutely to prevent ‘chronic pain’ becoming the presenting problem
Normalise the reality that psychosocial factors inform the experience of pain and recovery outcomes
Prevent the occurrence of secondary psychological injurySlide21
Psychological Assessment
The purpose of early assessmentIdentify relevant risk factors (differentiating between the different
flags)
and
make recommendations on treatment requirements
Triage who would benefit from psychological treatment based on identified risk factors
Inform patients, treatment providers & stakeholders about the identified risk factors, how they impact recovery & how they might be addressedSlide22
Psychosocial Assessment
Clinical Interview Identify thinking styles & beliefs about being injured, Explore contextual factors & ideas about recovery, Determine how patients relate to being injured at work
Screening Questionnaires
Validate against data collected at interview
Evaluate the ‘size’ of a risk factor
Communicate in quantifiable figures
Baseline factors for monitoring of treatment effect Slide23
Screening Questionnaires
Risk factor
Measure
Fear avoidance beliefs/behaviour
Fear
&
avoidance beliefs questionnaire (FABQ)
Tampa Scale of Kinesiophobia (TSK)
Catastrophic thinking
Pain Catastrophising Scale (PCS)
Stress, Anxiety Depressed mood
Depression Anxiety Stress
Scale (DASS 21)
Kessler’s Psychological Distress Scale (K-10)
Positive and Negative Affect Scales (PANAS)
Low self efficacy / Passive coping
Pain self-efficacy questionnaire (PSEQ)
Perceived function, disability & pain
Pain Disability Index (PDI)
Brief Pain Inventory (BPI)
Oswestry Disability QuestionnaireSlide24
Screening Questionnaires
Risk factor
Measure
Composite
measures
The Orebro Musculoskeletal Pain Screening Questionnaire.
The Start Back Tool
Shaw Back pain Disability Risk Questionnaire
Perceived injustice
Injustice Equity
Questionnaire (IEQ)
Justice Sensitivity Inventory
Perceived organisational support
Survey of Perceived Organisational Support
Perceived psychological contract breach (PCB)
PTSD
Post traumatic Check List - Civilian (PCL-C)
Personality types
Personality Assessment Inventory (PAI)
Millon Clinical Multiaxial Inventory (MCMI-III)Slide25
Early Psychological Treatment
What should be occurring in treatment Education with patients about the nature of pain & how psychosocial factors inform the pain experienceAddressing identified yellow & blue flags with patients via specific education & evidence based treatment (CBT)
Establishing with patients a recovery plan that is goal focused and measureable
Raise awareness and start the conversation early with stakeholders about collaborative solutions to identified blue & black flags
Engagement and collaboration with the treatment team Slide26
Early Psychological Treatment
Problematic psychological treatment Unnecessarily pathologising the patients’ experience ‘Hand holding’ therapy or harbouring the patient Failing to inform patients about the psychosocial risk
Not having or sticking to a treatment plan
Not measuring treatment outcomes
Continuing treatment when it is not working
Unnecessarily addressing underlying psychological issues
Not communicating with stakeholders about patients Slide27
Evidence on Early Intervention
Treatment targeting identified risk factors results in Better outcomes compared to;Interventions that ignored the psychological risk factors
Interventions that assume all physically injured workers have risk factors and require psychological input
These findings indicate that;
Assessing injured workers to identify risk factors is an important precursor to psychological treatment
Simply applying psychological treatment to all patients is counter productive and uneconomical
(Nicholas et al, 2011)Slide28
Evidence on Early Intervention
Outcomes are significantly improved when; Yellow flag are addressed in conjunction with blue & black flags being addressed via targeted workplace interventions
These findings highlight the criticalness of
;
Early psychosocial assessment
Early psychological treatment when indicated
Early dialogue between stakeholders to address risk factors beyond the injured workers’ control
(Nicholas et al, 2011)
Slide29
Barriers to Early Intervention
Fusion to the medical modelIgnoring psychosocial factors as normal & part of the ‘compensable injury’Cost & Liability concernsStigma and professionals’ ignoranceAccess to psychological servicesPatient resistance Slide30
Questions Now or Later
Scott Bevis Clinical Psychologist Dynamic Minds PsychologyPh: 0400 162 339Email:
dynaminds@bigpond.com