Understanding Psychological Injury

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