This is the third part of a series discussing what the rehabilitation professional must do to make himself or herself ready to make a difference in cases of psychological harm. Previously we have discussed taking stock of your own beliefs and attitudes and finding a model that helps you understand the specific facts in a wider context.

In the slapstick comedy, the three doctors show up to conduct surgery carrying garden and carpentry tools. A chase ensues as the patient goes screaming out of the operating room...

Most of the rehabilitation assessment reports that I have read start with a description of the events leading up to the claim that is identical to what has been recorded elsewhere. Those prior histories were taken and used to help determine legal liability and medical diagnosis. Information is one of your most important tools. Do you have the right tool for the job you need to do?

Don't settle for the same old story

By the time you see the injured person, they have told their story to the employer, claims manager, one or more doctors, assorted co-workers, friends and loved ones. They have seen it written out, probably more than once. Asking for another repetition is unlikely to gain any new information. It is likely to be seen as a mere formality by the injured person, who may wonder why you haven't bothered to read the prior reports of the injury, or may wonder if you are trying to "catch them" in a deviation from the previous versions. If the story contains an element of blame for others, the repetition may help solidify the belief and make reconciliation harder.

Generate new questions, based upon your model of harm

This is the time to use your model of harm. If you adopt a "disease" model, ask questions designed to elicit insight into what made this person susceptible as compared with others. Make sure that what is being labelled as a new condition isn't simply an increased focus on what was already there. Is the reaction a perfectly normal and reasonable one, given the circumstances? If this condition is more like a chronic sensitivity, then what triggers the unwanted response?

If you view psychological harm as an injury, then it is important to explore whether this is a single incident or just the latest in a series of small injuries. If it is "cumulative trauma" then exploration of the (failed) coping strategies previously used may be helpful. When was the first time the injured person became aware of the ongoing harm? Were the contributors from one or multiple sources? It may also be worthwhile exploring the fear-avoidance reaction typical of recovery from physical injuries.

If your model of harm is biopsychosocial, then it is critical to make a very wide ranging inquiry into the various "flag" factors that may be impacting on the injured person. Many checklists of these factors are available. It is probably wise to explore those that are susceptible to change in the context of the claim. But the inquiry must go beyond the existence of a "flag" and look to what causes that factor to have the impact that it does upon this person.

If the neuroplasticity model seems most helpful to you, then the timing of factors contributing to the harm at the same time is a critical inquiry. The participating event will be accompanied by thoughts, fears, emotional reactions and physical sensations. The repetition of those combinations becomes important to understanding how a "habit of thought" has developed. The sense of having lost control, and feelings of anxiety or fear about being able to cope, are common and strong motivators for change and must be explored.

Ask the injured person what they think they need to stop the suffering

By now you will have gotten the attention of the injured person by asking them questions that are different from what they are used to. Done skillfully, you will have shown a real interest in them as a person, which can help develop clinical rapport and cooperation.

Now is the time to ask what the injured person thinks that they need to stop their suffering. Surprisingly often, the injured person has ideas which may be implementable, but they just haven’t been asked. If the ideas are unrealistic, then it is important for them to know that part of rehabilitation is to create more realistic expectations. If the person has no input at this point, then the first task will be the creation of a realisation that improvement is possible, and something for which he or she may have to take a role.

The act of asking the injured person what they think they need is inherently empowering. Even if unanswered, it expresses respect and the importance of taking responsibility for recovery. You may also find that it helps establish a valuable relationship with injured person as well.