1. Early Psychological Intervention with Physically Injured Workers Scott Bevis Clinical Psychologist Dynamic Minds Psychology ‘Resilient Tomorrow’ TIO Conference October 2014

2. Overview The problem at hand Work injury & the biopsychosocial model Risk factors for poor outcomes Early psychological intervention Barriers to early intervention

3. The Problem at Hand The longer a person is absent from work due to illness or injury, the lower their chance of ever returning to employment (AFOEM, 2012) The longer an employee remains in a worker’s compensation system, the poorer their return to work and health outcomes will be (Konekt, 2013) Chronic pain is Australia’s 3 rd most costly health condition with an estimated economic cost in 2007 of $34 Billion (Access Economics, 2007)

4. The Chances of Returning to Work Time off work (AFOEM, 2012)

5. Return to Work Rates at 7-9 months The social research centre, 2013

6. The chances of returning to work Time off work AFOEM Position statement 2012

7. Contributors to the problem Adherence to the medical model Individuals..... we are all unique Compensation systems The neurophysiology of pain

8. The Medical Model Core assumptions There is a linear relationship between injury, symptoms & disability That by treating the underlying pathology the patient will get better Limitations Neglects the significance of the personal & contextual dimensions of injury and recovery Implicitly encourages passive recovery behaviour Colludes with patients’ unhelpful ideas about pain & recovery Treatment is escalated sequentially based on non- responsiveness

9. The Uniqueness of People Individuals bring along their own experience Thoughts, attitudes, & beliefs Feelings & emotions Actions & behaviours As informed by; Demographics, education, health literacy, personal & family history, personality & interpersonal style, etc.

10. Compensation & Recovery The purpose of workers’ compensation insurance is to facilitate optimal recovery and return to work following injury The compensation hypothesis - patients within compensation systems have worse outcomes than non-compensable patients The evidence is not conclusive (Spearing et al, 2012) Claimants do encounter additional factors – Dealing with the claims and settlement process – Exposure to medico-legal assessments, – Perceived lack of trust about having to prove an injury or disability. – The necessity of legal representation – Embitterment toward the system – strong sense of entitlement & injustice – An inability to move on with life during the claims process, (Mergatroyd et al.,2011)

11. Neuroplasticity & Chronic Pain Pain lasting beyond the expected healing time for the damaged tissue (3-6 months) Has a distinct pathology separate to the catalysing injury Associated with changes in the nervous system that continue to worsen over time Contributes to ongoing decline in physical & psychological wellbeing Poorly understood by patients (and treatment providers??) Best treated via a multidisciplinary approach (Pain Australia, 2014 ; US Institute of Medicine, 2011 )

12. Biopsychosocial Model

13. Adoption of the BPS model Now recognised & promoted by workers’ compensation authorities in Australia & NZ The Clinical Framework for the Delivery of Health Services (Victorian WorkCover/TAC) * The NSW WorkCover program and guidance The ACC Pain Management Services (NZ) Nationally Consistent Approval Framework for Workplace Rehabilitation Providers (HWCA)*

14. Risk Factors for Poor Outcomes In the context of work injury, there are numerous psychosocial factors that impact recovery These factors are often identifiable around the time of injury and if left unattended often become the maintaining factors The Flags concept was introduced as a framework for understanding and evaluating the personal and contextual elements as ‘risks factors’ Whilst not diagnostic ‘Flags’ signal specific obstacles to recovery and indicate where extra attention is required Provide a standardized language for dialogue about these features in everyday practice and between disciplines (Kendall & Burton, 2009)

15. Types of Flags RedIndicator of serious biological pathology YellowBeliefs, thoughts and attitudes about injury and context Emotional Responses to injury and context Pain Behaviours (coping style, how relate to injury) OrangePsychiatric symptoms BluePerception about the work and injury relationship BlackSystem and contextual barriers

16. Flags in the BPS Model

17. Psychosocial Risk Factors Fear avoidance beliefs/behaviour Catastrophic thinking Stress & anxiety Depressed mood Low self efficacy Passive coping styles Depression (MDD) Anxiety disorders PTSD Personality disorders Perceived injustice Inadequate support Excessive demands Low morale claims* Toxic workplaces Scope of RTW options Legal orientation Poor claims handling*

18. Yellow Flags Fear avoidance beliefs/behaviour Catastrophic thinking Stress & anxiety Depressed mood Low self efficacy Passive coping styles (Nicholas et al, 2011)

19. Early Psychological Intervention The risk factors for poor outcomes are known These factors are identifiable at or around the time of injury The aim of early psychological intervention is to; Assess for the presence of psychosocial risk factors, and when indicated Address the risk factors to reduces the potential for poor health and poor RTW outcomes

20. Early Psychological Intervention Why psychologists ? Experts in mental health Trained & experienced in the BPS model, psychological assessment and relevant evidenced based treatments Understand the significance of normal risk factors and capable of discriminating between the flags Why early? Address psychosocial factors acutely or sub acutely to prevent ‘chronic pain’ becoming the presenting problem Normalise the reality that psychosocial factors inform the experience of pain and recovery outcomes Prevent the occurrence of secondary psychological injury

21. Psychological Assessment The purpose of early assessment Identify relevant risk factors (differentiating between the different flags) and make recommendations on treatment requirements Triage who would benefit from psychological treatment based on identified risk factors Inform patients, treatment providers & stakeholders about the identified risk factors, how they impact recovery & how they might be addressed

22. Psychosocial Assessment Clinical Interview Identify thinking styles & beliefs about being injured, Explore contextual factors & ideas about recovery, Determine how patients relate to being injured at work Screening Questionnaires Validate against data collected at interview Evaluate the ‘size’ of a risk factor Communicate in quantifiable figures Baseline factors for monitoring of treatment effect

23. Screening Questionnaires Risk factorMeasure Fear avoidance beliefs/behaviour Fear & avoidance beliefs questionnaire (FABQ) Tampa Scale of Kinesiophobia (TSK) Catastrophic thinkingPain Catastrophising Scale (PCS) Stress, Anxiety Depressed mood Depression Anxiety Stress Scale (DASS 21) Kessler’s Psychological Distress Scale (K-10) Positive and Negative Affect Scales (PANAS) Low self efficacy / Passive coping Pain self-efficacy questionnaire (PSEQ) Perceived function, disability & pain Pain Disability Index (PDI) Brief Pain Inventory (BPI) Oswestry Disability Questionnaire

24. Screening Questionnaires Risk factorMeasure Composite measuresThe Orebro Musculoskeletal Pain Screening Questionnaire. The Start Back Tool Shaw Back pain Disability Risk Questionnaire Perceived injusticeInjustice Equity Questionnaire (IEQ) Justice Sensitivity Inventory Perceived organisational support Survey of Perceived Organisational Support Perceived psychological contract breach (PCB) PTSDPost traumatic Check List - Civilian (PCL-C) Personality typesPersonality Assessment Inventory (PAI) Millon Clinical Multiaxial Inventory (MCMI-III)

25. Early Psychological Treatment What should be occurring in treatment Education with patients about the nature of pain & how psychosocial factors inform the pain experience Addressing identified yellow & blue flags with patients via specific education & evidence based treatment (CBT) Establishing with patients a recovery plan that is goal focused and measureable Raise awareness and start the conversation early with stakeholders about collaborative solutions to identified blue & black flags Engagement and collaboration with the treatment team

26. Early Psychological Treatment Problematic psychological treatment Unnecessarily pathologising the patients’ experience ‘Hand holding’ therapy or harbouring the patient Failing to inform patients about the psychosocial risk Not having or sticking to a treatment plan Not measuring treatment outcomes Continuing treatment when it is not working Unnecessarily addressing underlying psychological issues Not communicating with stakeholders about patients

27. Evidence on Early Intervention Treatment targeting identified risk factors results in Better outcomes compared to; Interventions that ignored the psychological risk factors Interventions that assume all physically injured workers have risk factors and require psychological input These findings indicate that; Assessing injured workers to identify risk factors is an important precursor to psychological treatment Simply applying psychological treatment to all patients is counter productive and uneconomical (Nicholas et al, 2011)

28. Evidence on Early Intervention Outcomes are significantly improved when; Yellow flag are addressed in conjunction with blue & black flags being addressed via targeted workplace interventions These findings highlight the criticalness of; Early psychosocial assessment Early psychological treatment when indicated Early dialogue between stakeholders to address risk factors beyond the injured workers’ control (Nicholas et al, 2011)

29. Barriers to Early Intervention Fusion to the medical model Ignoring psychosocial factors as normal & part of the ‘compensable injury’ Cost & Liability concerns Stigma and professionals’ ignorance Access to psychological services Patient resistance

30. Questions Now or Later Scott Bevis Clinical Psychologist Dynamic Minds Psychology Ph: 0400 162 339 Email: dynaminds@bigpond.comdynaminds@bigpond.com