Effectively engaging treating practitioners in the RTW process for psychological injuries video transcript

Facilitator

I’m now delighted to introduce our next guest, Suzanne Gibson. Suzanne is a clinical psychologist and co-founder of HeadSmart Psychology. HeadSmart Psychology is an organisation dedicated to providing evidence-based psychological treatment for people with a compensation claim. Thank you for presenting to us today, Suzanne.

Suzanne Gibson

Thank you for the introduction Kayleen. And thanks for having me today. So as Kayleen said, today, I’m going to be talking about engaging treating providers when you’re managing the return to work for psychological injuries. And this is a topic that that I feel quite passionately about. So, I am a clinical psychologist now, and I work a lot with people who have a compensation claim. But prior to working in this role, I’ve worked in occupational rehab for 15 years. And so, a big part of that role, as I’m sure you’re all aware, is engaging with treating practitioners in the return to work process.

And what I’ve found in doing those roles is that, for whatever reason, often the treatment providers who were helping with the management of psychological injury, seem to be just that little bit more difficult to engage than treatment providers for physical injuries that I might be managing. And so today, I hope to give you some information from the treatment providers’ side, working as a clinical psychologist, and maybe give you some insight into how we conceptualise mental ill health. But then also pull in some of the experiences I’ve had in occupational rehab, and what I think tends to work from a return to work process perspective.

OK, so firstly, we’re going to be looking at how psychologists conceptualise mental ill health, and how that impacts on their work with compensable psychological injuries, and that there’s a little bit of difference between those two kinds of things. Next, we’re going to then look at some of the basics of communicating with treatment providers, and some strategies you can use to get those basics right to help with that engagement. And then also looking at some questions, which are likely to get you the most accurate information for guiding the return to work process.

Next, we’re going to look at then how some of the evidence-based treatment approaches for psychological injuries align quite nicely with the return to work process, and how you might be able to use that alignment in your negotiations with treatment providers, to really demonstrate that return to work is part of treatment.

And then finally, we’re going to finish off with just some strategies that can help for challenging treating practitioners. I’m sure we’ve all had the experience of working with a treating practitioner who may not perhaps be as supportive of return to work as we would like them to be, and so we’re just going to finish off with some tips around challenging in that kind of situation.

Just a little note on terminology before we get started. Throughout the presentation, I will be referring to the client. And by client, I mean employee or injured worker or claimant or whatever on the term you tend to use. I just tend to call those people who have come to me for treatment, clients. So that’s the terminology I’ll be using throughout this presentation.

OK, so let’s start by talking briefly about how psychologists’ approach mental ill health. It started with our conceptualisation of mental ill health. Because I think that this is an area where there’s quite a big difference between how we conceptualise mental ill health, and how we conceptualise physical ill health. Ben, do you mind going to the next slide, please? Thank you.

So, I guess from a medical model perspective, the way we tend to think about injuries is that something is broken, and when are we going to get it fixed? How are we going to move towards it being fixed? But that’s a little bit different to how psychologists might conceptualise mental ill health. And what we tend to think of is mental health as being more on a spectrum. So, if you think about your level of mental wellness, I guess, as being on a particular spectrum, where there’s different radiance of wellness. And down one end, we might have someone who’s quite overwhelmed. So, they might be experiencing high levels of distress. They’re finding it difficult to perform their activities of daily living. They’re not feeling like they’re achieving the goals that they want to achieve. That’s down one end of being overwhelmed with mental ill health.

And then right at the other end, we might have someone who’s flourishing and experiencing good mood a lot of the time, and achieving the goals that they want to, and being able to engage in their life in the way that they want to. And then in between those two extremes, we have a whole bunch of different gradients of mental wellness. And we’re all at any one time sitting on that spectrum. The thing is, though, is that we all might have something that takes us down that spectrum at any one time. So, we can have a particular stressor that makes it more difficult for us to be able to cope with what’s going on in our lives.

And so I guess I feel like this is important to understand, because when we’re approaching someone who has come to us with some sort of psychological issue that they want help with, we’re really approaching it in terms of this conceptualisation. So, in terms of, what is it that’s happened? What are the factors that have taken this person down this spectrum? And where are they currently sitting? And what is it that we can help them with that’s going to get them back up this spectrum? So, it’s very much not a broken versus fixed perspective, it’s very much an OK, how can we help this person gradually back up, get back up to where they want to be?

And so, what that means then is that when we’re approaching someone to provide them with treatment for a psychological injury, we’re really thinking more in terms of case formulation, and treatment goals, reaching treatment goals, more so than diagnosis and recovery. You might pick up that this is in some ways misaligned with how compensation scheme works. Because really, a compensation scheme is about figuring out is there a diagnosable injury, has it been caused by work, and when is it that this person is going to have recovered enough that we can say that there’s no longer a diagnosable injury?

So I think that this can sometimes be a point of friction between treating psychologists in particular and the other parties in a compensation scheme, is that the way that we’re conceptualising what’s going on for someone is slightly different to the way that the other stakeholders in the process might be conceptualising it. But if you can understand this, then that gives you the starting point for being able to communicate with the treatment providers for mental ill health in a way that engages them a little bit more.

So, I also just wanted to give an overview of what the therapeutic process involves. So, we will always start out with an assessment of the presenting problems that someone has come to our clinic with, and the symptoms that they’re reporting. Once we’ve done our assessment, then we come up with our case formulation. And so, a case formulation is our understanding of all of the factors that are currently causing this person to feel distress, and currently impacting on their ability to function.

So, we tend to focus more on case formulation than diagnosis, because diagnosis is just one piece of the puzzle. It can be important, and it can certainly be important in terms of directing the evidence-based treatment. But it’s just one part of what we want to understand about a client. We really want to understand the whole picture of all of the different factors that might be impacting on them.

The next step, then, is to develop our treatment goals. So, we’ll do that in collaboration with our clients. And what we really want to understand is, what is it that they want to change through the therapy process? Where is it that they want to get to, what do they want to be doing differently? When we’re working with people who have a compensation claim, we really hope that going back to work is one of those goals. Because returning to work is a really important part of functioning in the way that they did prior to having their injury. But we’ll try and make it open and allow them to pick what treatment goals they want to work towards. Because then they’re going to have more ownership over it. Jacqui just spoke a little bit about that, of allowing someone to have the choice and the agency to be able to direct their treatment. And we will certainly encourage them to consider return to work along the way as well.

Then we provide therapy and give them strategies and help them to try and work towards those treatment goals. After a certain amount of time then we will review progress against those goals, and figure out how close we are to them, whether they need to be revised, whether there’s new goals that someone wants to keep working towards. And then finally after that, we’re reassessing the symptoms, which is part of our formulation around diagnosis.

But I guess what I’m really trying to emphasise with this is that it’s not necessarily the most important part of what’s going on. We’re really trying to understand all factors and understand how someone wants to make progress and helping them to make progress towards those goals.

OK, so hopefully that gives you a little bit of a flavour of what a psychologist’s approach is to treat someone with a psychological injury. So, let’s move on now to some strategies that I hope will help you in your communication with the treatment providers.

So, these are just some basics that can be really helpful in getting your treatment providers buy-in when you want them to communicate with you. The first is around providing evidence of consent. So, I understand that sometimes in a compensation scheme, consent is in some ways implied. But psychologists have a very high level of responsibility around confidentiality. There’s both from a treatment perspective, treatment being effective relies on people recognising that the information they give us is going to remain confidential. But there’s also a number of quite strict legal requirements around confidentiality. And so, it’s likely that a psychologist will ask you for evidence of consent. You’ll make your own life easier if you’re able to provide that evidence up front.

Whenever you’re speaking with the treatment provider, and this applies to both physical and psychological injuries, being able to communicate with that treatment provider what you’re trying to help the client work towards, how the return to work process is going to be helpful for their patient. When you’re able to do that, you’re tapping into what that treatment provider’s motivation is most likely to be. So, all treatment providers, or I shouldn’t say all, but you know, most have at the centre of what they’re doing the welfare of their patient. And so if you’re able to communicate with them about how this return to work process is going to help that patient reach their own goals, and return to the life that they had before they had an injury, then that’s going to make it more likely that they’ll be engaged in the process with you.

This next point I wasn’t able to find any evidence for, so this is really my own anecdotal experiences. But what I did find in trying to engage with psychologists when I was managing return to work is that they seem to have a bit less of an understanding of how compensation schemes work than other treatment providers, such as physios. So, you guys hold a really unique position in that you understand how the Comcare system works. So if you are able to provide some education to the treatment providers on how Comcare works, and how their treatment decisions might be impacting on the claims process, then you’re giving them the information that will help them make better decisions.

It’s also important to remember that a treatment provider is getting a biased perspective on what’s going on at the workplace, or in the return to work process. They are usually only hearing mainly from their patient. And so again, you hold a really unique position, in that you have a much wider lens on what’s going on. So again, being able to provide that education around the whole process, and the elements that are coming from other stakeholders can be really helpful for making sure that treatment providers, when they’re making their decisions, understand everything that’s going on.

And this final point is really just a small logistical point. But really trying to make it easy for a treatment provider to communicate with you, goes probably much further than you realise. It’s not always easy, I guess, to be able to find the information that you need us to provide to you. So, if you can make it as easy as possible for us to communicate back to what you what you need, then you will be more likely to get that information quickly and accurately.

OK, so there’s some of the basics. Now I wanted to talk about some questions that I think are most likely to get you the information that you need to firstly set up the return to work process, and then guide the return to work process as you’re going through.

So, I do get asked by a lot of insurers and employers and rehab providers, what the diagnosis is for my clients that I’m working with. And I’m happy to provide that. But I actually sometimes wonder how helpful knowing the diagnosis is in guiding the return to work process is. A diagnosis is really just a label for a bunch of symptoms. And so, I think that a more effective question could be asking about what all the factors are that are currently contributing to a client’s distress. It gives you a more holistic picture of what’s actually happening for that client, and also gives you the ability then to figure out, OK, what might be some things that could change that would facilitate this person’s return to work?

Again, then asking about the treatment goals for this client, so really trying to get an understanding from a treatment provider of where is this process heading? And what is it that the client would like to get out of this? Again, because that will be something that you can factor into the return to work process.

Then asking around the barriers to reaching their treatment goals, so that, again, you can understand if there are ways that you might be able to help to remove some of those barriers. For example, are there things at the workplace that are currently getting in the way of the client getting to the goals that they would like to get to? And also asking around what support strategies would help the client when they start their return to work.

So I have, unfortunately, had a situation recently where I started working with a client, she wasn’t ready to make her return to work, we kind of did a bunch of stuff, and she got up to the point where she was OK to start that return to work process. She was experiencing quite high levels of anxiety. And then one of the things that had been something that had really fuelled her distress was that she felt like she’d been ignored at the workplace, she hadn’t really had her concerns listened to. And on her first day back to work, she was put by herself, in a back room doing a task that she didn’t find particularly engaging. And it was a real shame that that hadn’t been addressed, there could have been some very simple things that could have been put in place. Because what then ended up happening is, she didn’t actually continue with that return to work process, her anxiety flared, and it brought up all of those old feelings around being ignored.

So being able to ask, preferably before the return to work process starts, what are the support strategies that are going to make sure this return to work process is successful, can mean that you’ve got that opportunity to put those things in place, and really try and overcome those barriers before they even come up.

If you’re asking for information about the duties that a client can and can’t perform, it’s important to remember that, again, you guys hold a unique position. You understand the workplace, you hold the information about what the workplace entails. And a lot of doctors and psychologists don’t necessarily have information about what certain duties involve. So if you’re able to provide the actual demands, not necessarily just the tasks, but even the demands that are required in the role that someone will be returning to, then you’re more likely to get accurate information about what they can and can’t do.

And this last one is actually related to something that Jacqui mentioned around recovery and return to work, in that it’s not often in the case of psychological injuries that we have set timeframes that we understand will mean that someone’s recovered from their psychological injury. It’s often about the barriers that might be in the way of someone making that recovery. So rather than asking about the timeframe for a return to work to be started, or for an upgrade to happen, my recommendation would be to ask about what barriers are standing in the way of that happening? Because it probably gives you more accurate information. But it also then gives you another opportunity to work on removing some of those barriers to facilitate that return to work process.

OK, so there’s some questions that you might want to use next time you’re engaging with the treatment providers. And so now I just wanted to illustrate how some of the evidence-based treatment approaches for some of the more common psychological injuries align really nicely with the return to work process. And the reason for doing this is because this can help your conversations with the treatment providers throughout return to work, in being able to bring back what’s going on in the return to work process, in terms of its alignment with the treatment process, and really being able to illustrate with a psychologist or a GP, how what’s going on at work actually aligns with what’s going on in treatment.

OK, so the first treatment strategy is something which is called behavioural activation. And it’s often used for the depressive disorders. And what behavioural activation means, is that we use activity to help to lift mood. So again, as Jacqui mentioned, when we’re disengaged from activity, when we’re not doing things that we enjoy, that can often have an impact on our mood. And so, planning and engaging an activity that someone either finds enjoyable, or gives them a sense of achievement can be a really good starting point for improving their mood.

So, there’s lots of ways in that return to work aligns with this. If someone’s able to re-engage back in work, that in itself is re-engagement and activity. Perhaps doing some duties they really enjoy. Starting some volunteer work. I know that may not always be possible, but if it is, then that can be a way for someone to get that sense of achievement. Doing some retraining, an exercise program, perhaps going to job seeking sessions, or really any activity, if someone’s really disengaged, can be a really good starting point for lifting mood and helping them to then work towards the goals that they want to.

The next one is around goal setting. And again, it’s used for the depressive disorders, although it’s something that we often do with really anyone who comes and sees us in the clinic. And one of the ways that goal setting is helpful for people, is that it’s a way of stopping that rumination, that ongoing rumination on what’s happened to them in the past and helping them to take a more future focus. So really helping them to look at what they want to work towards, to help them start to take action towards that. And as you guys are probably well aware, goal setting is an intrinsic part of the return to work process. And there’s a nice alignment there between those two things.

The next strategy is one which is used for the anxiety disorders and PTSD. And there’s a lot of evidence to support the use of this strategy. So, this one is called graduated exposure. And what it involves is when someone is feeling anxious about a particular situation, or a particular thing, putting them in that situation, or in the presence of that thing that makes them feel anxious. And the reason that that is used as treatment for anxiety, is because it uses a principle which is called habituation, which basically means that with a repeated exposure to something that makes us feel anxious, our anxiety will naturally decrease.

So if you think about perhaps your first day of work in a new job, you might have felt quite nervous before going there on that first day, then by the second day, you might have still been a bit nervous, but a bit less nervous. And then by the fourth week, you probably didn’t feel much nervousness at all. And so that’s a process of habituation. And we use that when we’re helping people to overcome anxiety, to help them to decrease that anxious response that they they’re getting.

So that again really aligns very nicely with the return to work process. If someone is feeling really anxious about returning to work, then actually getting them to re-engage with work and go back into the workplace is a way of providing that exposure process. There is a caveat to that in that it needs to be done gradually. And it needs to be done in a supported fashion. So, we would never throw someone back into the lion’s den, so to speak, and put them in that situation that makes him feel extremely anxious. We would try and start with things that make them feel a little bit anxious, and then gradually helped them work their way up to back to that thing that was really hard for them to do.

So, these next three strategies are really more symptom management strategies. And the way that they can be used in the return to work process is by allowing the person to stay at work, stay in the workplace, but giving them some tools to be able to manage their symptoms while they’re there.

The first one is called breathing retraining. And I always feel that this is a very fancy name for quite a simple process. All it really involves is teaching someone to slow down their breathing. And it’s used mainly with people who are experiencing high levels of anxiety. And the reason it can be effective is because when we feel anxious, we get some physiological responses to that anxiety. And so, by slowing down your breathing, you’re actually reversing some of those physiological responses. So for any of my clients who are experiencing anxiety and are starting the return to work process, we always do a little bit more practice of this before they go back, so that they remember that when they’re at the workplace, and the anxiety starts to increase, they’ve got that ready to go.

Active relaxation is also a strategy that we will use for people who are feeling quite keyed up all the time. And it can be done in several different ways. Meditation is used quite a lot now, or progressive muscle relaxation. But even just doing relaxing things can be helpful. And again, it’s just a way of managing the kind of nervous system response that we get when we’re trying to manage distress. So, this can be encouraged for people who are trying to manage that return to work process, to be able to manage the symptoms as they’re going along.

And finally, this strategy I’m sure is one that you’ve all heard of, because mindfulness tends to be everywhere now, and we tend to use this for people with most presentations, is teaching them some mindfulness skills. And the idea of teaching mindfulness is to help someone to be able to engage what’s called present mindedness. So not being caught up in rumination on the past or worrying about the future but trying to be present in the moment.

And so again we’ll often be doing that sort of training in the clinic, in treatment, but it’s something that they can call upon when they’re trying to manage the return to work process, just to help them to manage those symptoms.

OK, so that’s the alignment of return to work and treatment. And so, I just wanted to finish off by talking briefly around being able to challenge treatment providers. There are times when I’m sure we’ve all had our frustrations with some treatment providers. And so being able to challenge in a way that still keeps them engaged, and still reinforces how what you’re doing has the best intentions of their patient in mind will be really helpful.

So, I guess the first strategy is calling upon what we just talked about, which is that return to work is absolutely a treatment strategy. There are some cases where some people probably can’t return to work, but they are most definitely the minority. And certainly, most of the people that I see return to work. Going back to work would be one of the best things for them. It would allow them to return to something that they enjoy, that gives them structure and routine, that gives them social engagement. And so, return to work is absolutely part of their treatment, it’s going to aid their recovery.

So whenever you can remind treatment providers of that, and really illustrate to them how returning to work is going to help the client work towards the treatment goals, then the more likely you are to be able to challenge maybe some of their reluctance around the return to work process.

And finally, this is probably something that you’re all well aware of. But there is a really handy document for all of us. And in fact, a signatory steering group now on a website that has a lot of resources, which is based on the health benefits of good work. So, as you probably know, this is a consensus statement that was developed by AFOEM and the RACP in 2011. And what they did is they collated all of the scientific evidence that demonstrates that returning to work is not just protective of our health, but it can also help us recover from ill health.

So, what I really wanted to emphasise with this slide is that this consensus statement doesn’t just talk about how return to work is good for our physical health. It also directly addresses how it helps our psychological health as well.

So, there are just two quotes that I pulled out from it that I think are most helpful:

“Suitable work has been shown to benefit people suffering from a wide range of psychiatric conditions. These conditions include anxiety, depression, bipolar disorders and schizophrenia.”

And the Mental Health Council of Australia advises that.

“Early intervention is an effective way to support people with mental illness back to work. In fact, the longer that someone with a mental health problem is out of the workforce, the harder it becomes for them to find work and sustain that employment. And so that can be a really helpful document for you to be able to use or even just call upon in your negotiations with treatment providers, because it really illustrates how return to work is often, and most often, the best thing for people who are suffering from ill health.

So that’s it for my presentation. I hope there was some helpful strategies in there for you, and I believe now there might be some questions.