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Understanding Psychological Injury Dr. James Arnold, RDPsych
What is a Psychological Injury?
Specific incident Series of incidents, cumulative –
usually less intense than the specific incident situation
Chronic overwork –
e.g., performing two jobs, burnout with excess job hrs and demands
Typical Origins of Incidents
Happened personally to worker, e.g., involved in fatal MVC Happened to another worker, i.e., observed, attended to injured worker
Interpersonal, e.g., assault, harassment, threat
Arose from the injured worker's behaviour, e.g., with equipment
Arose from another worker's behaviour
On a continuum with the type expected work, or completely out of expectations
Critical Incident Stress Management
Education and information aspect is helpful – – –
Where to get help, resources What to do in immediate aftermath Communication of company responses
Some forms of discussion may be harmful – –
A group may respond to the most traumatised person and gravitate to that level Some debreifers not involved in the incident may be working out their own prior trauma
DSM: Diagnostic and Statistical Manual of Mental Disorders
DSM-5 replaced DSM-IV DSM lists symptom clusters, does not specify how to diagnose DSM is descriptive, does not specify causes Updated criteria so that direct contact with injury situation is required for a trauma incident exposure to qualify
Typical Diagnoses
PTSD (post-traumatic stress disorder)
ASD (acute stress disorder)
Adjustment Disorder with depressed/anxious/irritable mood Some symptoms of psych trauma, not full syndrome – “Other Specified Trauma- and Stressor-Related Disorder”
Depression
Panic Disorder
Agoraphobia
PTSD Criteria
Life threatening or horrifying incident
Intrusive recall
Psych & physical over-arousal, and/or emotional numbing Avoidance to control other symptoms Delayed onset is possible, usually in response to triggers
ASD
Short term psychological trauma symptoms Initially dazed or in shock, with fluctuating and unstable symptoms May last up to 1 month, usually 2-4 days
Immediate emotional reactions: depression, anxiety, anger, despair Behaviour may be hyperactive, withdrawal from others Sleep, appetite, routines all disrupted
Adjustment Disorder
Temporary psych symptoms in the presence of a stressor Not a life threatening or horrifying stressor May show similar symptoms of depression, anxiety, irritability etc., akin to a trauma
Diagnosis Three levels of diagnosis for WCB Reason for Visit (RFV) Working Diagnosis (WD) Full Assessment Diagnosis (FAD)
RFV (Reason for Visit)
Why patient is seeing the doctor Brief, symptom oriented visit A diagnosis is provided to describe the visit Limited or no diagnostics
WD
Worker is attending appointments with a counsellor, therapist, psychologist Focus of meetings is on work incident, symptoms and managing Diagnosis based on worker's report of symptoms and applying an understanding of typical symptom clusters
Full Assessment Diagnosis (FAD)
Worker referred for a “Mental Health Assessment” Contains the self-report of symptoms and issues Psychological testing and assessment Application of statistical data re functioning Projection re return to function Specific specialist treatment recommendations
Not all Testing is Created Equally
Checklist testing is obvious in content, though systemizes clinical inquiry Multi-dimensional testing is both obvious and non-obvious, and statistically relates to symptoms and diagnoses
Validity of presentation of symptoms is also assessed We have disability and injury comparative groups
Medical-Legal Standard
WCB has to apply a medical-legal standard to information provided by practitioners Uses the understanding of levels of diagnosis (RFV, WD, FAD) and source of information Injury and symptoms are related in a “clinically plausible” manner to diagnoses Clinical plausibility is more than a sequence in time, applying a broader understanding of person and bio-psycho-social factors
Increases in Previous Diagnoses
Prior disorders or problems may be made more intense or symptomatic after an incident Temporary increase, permanent increase are all assessed Psychosocial adjustment may be compromised post incident, e.g., family and relationships, substance use, mood
Who Can Diagnose?
MD, psychologist, social worker, other professions Diagnosis must be weighed as to type of evidence and data which supports it SK is among jurisdictions which are broadening who can diagnose
Motivation seems to be both public system cost savings and lack of professionals Problems when applying medical-legal standard
Primary Psychological Care
Typically: – Once per week therapy for 1-1½ hours – Rest of time often unaccounted and without routine Role conflicts and adoption of “sick role” But: often all that is required if already working or RTW is planned to start soon
Enhanced Mental Health Program
Began as pilot in spring 2016, generally available fall 2017 Provides:
2-3 hours per week psychological therapy 3-5 days per week of 3-5+ hours in a rehab clinic Supervised exercise program Additional behaviour therapy supervised by the psychologist Compressed treatment time frame, earlier RTW
Mental Health Program - Why?
Data:
Physical activity assists with mood Mindfulness is encouraged by physical exertion Hormonal effects of physical activity Daily routine assists with recovery Daily social interaction physical rehab clinics have experience with RTW and TRTW
Reduced time off work – expectation is discussion of TRTW within first weeks of program
Mental Health Program
Proof of success will be earlier RTW Shorter duration of time loss Data so far: earlier RTW, less permanent restrictions
This is at the level of case-by-case so far
Task Performance and Psychologically Injured Workers
Sleep loss & fatigue Concentration, memory, focus Depressed, downcast mood Fearful and extra cautious Experiences of anxiety may impair focus Reduced social behaviour Prior personality is more intense
Best Practices for RTW
Contact is key - don't avoid − −
Greetings, thoughtful talk, small gestures Indicate willingness to accept back in different temporary role
Express positivity, avoid intrusiveness Instructions to employees to respect privacy and leave lead in talking to injured worker Offer info re safety changes, request input If possible, delay labour relations post-RTW
Treatment and the Workplace
Contact with you as a “secondary client” − −
May request use of workplace for treatment: − − −
You will be informed that worker is enrolled in treatment expect a call within 2-3 weeks of start, call WCB if not Exposure in vivo (live exposure) Workplace meeting and/or tour Privacy issues
Temporary restrictions, usually for locations, sometimes people, may combine with physical.
Expectations of Treatment Providers
Avoid labour relations Avoid advocacy for specific job, though may approve job descriptions as meeting restrictions Approve early RTW when possible −
Data show that earlier return encourages recovery
Help avoid − −
secondary psychosocial effects the “sick role” and lack of daily routine
Psychotherapy
Self-control of mind and body − − −
Cognitive-behaviour therapy Behaviour therapy Exposure therapy
Contain the trauma Associated behavioural issues Psychosocial counselling ± in combo with medication
Providers of Psychotherapy
EFAP counsellors might not: − −
meet WCB standards for psychology be able to provide assessment at level required
−
Reason for visit Working diagnosis Full assessment diagnosis (medical-legal)
provide in-person treatment
Psychologists are not Licensed Equally
PhD, PsyD: 5-6 years of training + 4 yrs.. undergraduate M.A., M.Sc: 2 years + 4 yr. undergrad M.Ed.: most often 1-2 yrs. school-related training Areas of training and expertise might not match worker's needs EFAP companies may offer out of province and not in person
Questions & Comments