Previously, we discussed the first step in becoming more effective in assisting people with psychological injury to recover and return to productivity. That step required us to take a look at our own attitudes and beliefs, and determine our personal characteristics when approaching these cases. In this part of the discussion we'll establish a "model" in which we can understand the situation we are trying to intervene.

Have you ever tried to find a specific location in a city with which you were unfamiliar? Without a map, it can be pretty hit and miss. Sometimes you might find your way by luck or accident. Often it takes a lot longer, if you get there at all.

Trying to help a psychological injury claimant return to work without a "map" of what is happening to them is a lot like that.

We always work with maps or models of our expectations – what we usually call a "rule of thumb” – to help guide our actions. The trouble is that many of the rules of thumb that work for physical injuries fail for psychological injury. There is no outward manifestation of injury and self-reporting plays a huge role. Treatment varies widely in approach and efficacy, and without reasonable expectations about recovery periods, the rehabilitation professional often opts to merely coordinate the efforts of others.

There are a lot of "maps" of psychological injury to choose from. What's important is not that you choose some expert's preferred approach, but that you choose an approach that has practical value in most of the cases you undertake. The map you choose will be successful if it assists you in suggesting a helpful course of action for an injured person, and not merely by being the one that is the most familiar or comfortable for you.

Here are some options¹:

Psychological harm as a disease

Diseases are "a pathological condition of a part, organ, or system of an organism resulting from various causes, such as infection, genetic defect, or environmental stress, and characterized by an identifiable group of signs or symptoms". Psychological harm isn't contagious in the sense that communicable diseases can be shared. But, psychological harm can be "cured" by the passage of time (as in most PTSD) or by appropriate treatment. Sometimes psychological ailments resemble chronic diseases such as malaria or chronic sensitivities, such as allergies, and the triggers for instances of harm are important.

People who believe in the disease theory of psychological harm have to deal with at least two issues. First, not all people react to the "cause" of the harm in the same way. Some people appear immune to some or all of the harm, and different people may recover more or less quickly, depending on unexplained factors. Second, the disease theory defines the condition as pathological, while we understand from common human experience that some psychological reactions (like grief at the loss of a loved one or anger at genuine injustice) are entirely appropriate to the situation.

A disease has a diagnosis. Most often a disease can be either cured or controlled, but some diseases are chronic or progressive. Treatment of a psychological "disease" sometimes suggests removal of the cause, rest, or medicine to address signs and symptoms.

Psychological harm as an injury

This is a familiar model in physical medicine. Injuries may be either the result of a single significant trauma or the accumulation of small traumas over time. What constitutes an injuring event appears to vary from person to person, and situation to situation.

Once again, what harms one person doesn't harm every person subjected to the same events, and doesn't affect people in predictable ways. Moreover, people who adopt this view must deal with the issue of secondary harm. It is clear from common experience and research that some people who suffer a physical injury have something else happen to them over time, such that they remain (or become) unwell even after the original physical injury has resolved. This psychological injury as a sequel to physical harm should have its own injury to explain it – but what injury is that?

An injury has a diagnosis, and treatment (and/or natural healing) can usually repair the damage to a greater or lesser degree. Treatments for psychological harm by injury would also appear to include separation from the source of the harm (especially when caused by repetitive small traumas), rest and medication.

Psychological harm as a biopsychosocial phenomenon

The "flag" system – of identifying factors that impact on the likelihood of return to work – is based on the insight that the entire environment impacts on the response of a person to something that happens to them. This approach is strong in understanding why some people react more adversely to a particular situation than others.

The issue confronting people who adopt this theory is how to gather and use the necessary information. Research has correlated poor return to work outcomes with many different factors, some of which arise from historical or external environmental issues that are not easily affected by outside intervention. An additional question arises from where the "tipping point" for each individual falls. Biopsychosocial indicators are determined at a "population" level and do not predict individual reactions.

Prevention of harm has been attempted by way of providing early intervention for people who are injured and identified as being at risk. Treatment after the fact is more elusive. Where factors contributing to the harm include education, socioeconomic status and the quality of external relationships, intervention strategies may appear beyond the scope of the claim.

Psychological harm a neuroplastic phenomenon.

Recent advances in brain science suggest that the brain processes all the stimuli with which it is presented at the same time, and makes associations between them. With sufficient "practice" the connections between these thoughts, emotions and physical sensations becomes habitual and automatic. Where a sense of loss of control and anxiety about the future are involved (as in most unpleasant situations at work) the habitual thought pattern may influence the way that a person thinks of themselves and relates to the world ². Changes in how we think about ourselves may constitute some or all of the psychological injury. This approach considers all the factors that a biopsychosocial approach does, but suggests that the repetition of mental connections between perceived factors are the key to treatment.

This model explains why certain systemic influences, such as the presence of a lawyer in the claim, have demonstrated negative impacts on recovery and return to work. It includes elements of the biopsychosocial model. This is helpful when considering why some people react to situations that others find tolerable.

Treatment under this model of psychological harm looks to change the meanings or associations between the messages the brain is processing, to reduce the repetition of unhelpful connections. There are a variety of appropriate techniques suggested by this model, including well-focused cognitive behavioural therapy.

Pick one

What's important is that you find a model that works for you and the workers with whom you interact. Your success rate should be your guide in deciding whether the model is useful.
 

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¹ These are only a few of possibilities: fear –avoidance models and "failure of resilience" models also have strong points, but space limitations prevent detailing them here.

² See Aurbach, R., "Suppose Hippocrates Had been a Lawyer, A Conceptual Model of Harm to Litigants", Psychological Injury and Law (2013) 6:215-237, and Aurbach, R., "Breaking the Web of Needless Disability" Work, A Journal of Prevention, Assessment and Rehabilitation (2013) http://iospress.metapress.com/content/y50n1479vj054364/?p=7d6ab3539cd840bea6e14dbe8f2874dd&pi=0