FINANCIAL SECRETS
Question:
"Wanted to wish you a Happy New Year and also to ask a question: What single
factor do you believe is most problematic in returning an ill or injured
worker to productivity."
Answer:
"I believe it is the financial myths that patients carry. They are told that
if they get better, they will receive less money. They are told that those
who are treating them are only invested in payment for services, not their
recovery. They become preoccupied with the financial value of their physical
or mental problem. And of all the intimate topics that they will discuss,
they characteristically become all-but-mute when it comes to discussing
money.
Even patients of otherwise high integrity
appear to be corrupted and misdirected by the concept of financial value. It
is also almost an impenetrable topic wherein they dwell on the concept of
value of their disability and perceive that others are invested in
diminishing that value.
Regardless of the degree of distortion or
sometimes even partial accuracy of some of their perceptions, this
preoccupation interferes with the continuity, comprehensiveness, compliance
and effectiveness of care.
The approach I have always taken is to tell a
patient from the onset that my responsibility...and their
responsibility...is solely for recovery and that other issues need to be set
aside and that the focus needs to be exclusively upon the treatment process
and their compliance with it.
THE FAMILY:
Question:
"Thank you for these case management concepts over the past year. Best
wishes and happy holidays to your family. I also have a question. Does the
patient's family facilitate recovery?"
Dr. Adams Responds:
"Happy holidays to you as well, and if your E-mail supports it, I have
included a photo of the most recent Santa experience.
Now, in answer to the question:
The family should facilitate recovery, but my
experience has been that most often it facilitates disability.
Quite often, the family:
a. increases the patient's expression of
dependency,
b. encourages the patient to take greater amounts of medication so that the
family will have to listen to less complaints,
c. reinforces the patient's anger and frustration
d. exacerbates the patient's fear of abandonment
e. increases the patient's blame of others for what has happened to them
f. increases the patient's suspicion of those involved in their care.
This is often worse if one or more family
members are also, in some manner, disabled.
Often a nurse case manager can assist the
patient in more accurately perceiving options and outcome.
It may also be necessary to remind the family
that their actions are merely increasing the patient's perceptions of
disability."
HYSTERICAL COMPLAINTS:
Question: "You have
mentioned hysterical patients but not what we should look for in such
cases?"
Dr. Adams Responds: "The
term hysterical comes from hysterus (implying "wandering uterus") since the
earliest observations of these patients was that their complaints migrated
from one site to another. Fix one thing and up crops another.
It is now referred to as
conversion disorder (we'll discuss next week) often concurrent with
histrionic personality disorder.
Such patients are uncomfortable
when they are not the center of attention, their behavior is provocative (if
not seductive), and while they are rapid in their expression of emotions,
the emotions are chiefly shallow and exaggerated.
Histrionic patients use physical
appearance and complaints to draw attention to themselves. They are
dramatic, and they are easily influenced by others. While they can ramble
endlessly and dramatically, what they tell you actually lacks detail.
For those managing such cases,
they are often struck by noting that the histrionic patient's relationships
are shallow while the patient feels the relationships to be emotionally
intimate.
This is a pervasive pattern,
largely established by early adulthood and characterized by attention
seeking and excessive emotional expression.
When such patients believe they
are ill or injured, they use their physical complaints to meet secondary
gain needs for attention, affection and often relief of responsibilities to
care for others for whom they would otherwise be responsible."
NARCISSISTIC INSULT:
Question: "You stated last
week that you would clarify about a patient’s narcissistic insult. Is this
something they do?"
Dr. Adams Responds:
Narcissism is excessive self-involvement. The patient sees themselves as
being possessed of great talent or achievements and wants recognition for
their superiority.
They perceive themselves as
powerful, brilliant and/or beautiful, and they believe that they are
special, unique and want a great deal of admiration.
They have a sense of entitlement,
expect favorable treatment or automatic compliance with their wishes. They
tend to take advantage of others, and they lack the capacity to identify
with the needs and feelings of others. They are often arrogant and haughty
and believe that others envy them.
Their belief system is, however,
often fragile and can be easily shattered by an injury or illness which
deprives them of some (often superficial) attribute (ability to hunt,
physically fight, engage in extramarital affairs, display purchased objects,
etc) upon which they built this concept of being special.
An injury (or illness) then becomes an “insult to
their narcissism.”
They then become angered because they are no longer
seen as special. Sometimes they become depressed, not by the injury, but by
the loss of ability to make demands upon others.
They become hostile, more arrogant and
demanding, in an attempt to reclaim their role. They fail to realize the
true importance of their lives, and view everything in terms of whether it
makes them look better…or is an insult to them.
CONDITIONED HELPLESSNESS:
Question: "You made
fleeting reference to the concept of “helplessness” and I am uncertain that
I fully understand. Were you saying that helpless people commit suicide?"
Dr. Adams Responds: If we
look at those who are disabled or claim to be disabled, and you separate out
those who are validly, clinically, depressed, we find that the depressed
patients feel helpless. They believe that there is nothing which they
personally can do to change their plight. They believe that they have
depleted the family, emotional, and financial resources…which may have
already been limited.
They lack the educational
background to create new careers, and they often lack the intellectual
capacity and/or (youth if not) physical capacity to embark upon a new course
in life.
It is offensive and vexing when
someone claims to be depressed but is actually merely sullen and
retaliatory. But it is also irresponsible not to recognize those patients
whose limitations have resulted in their feeling that they had depleted
their reserves, at all levels, and that they can foresee no viable support
level upon which to rely.
Often, treatment for such
patients is the ability to redirect them to find areas in which there is
competence for a viable and productive future.
Obviously, it must first be
determined that it is depression which the patient is experiencing and not a
characterological problem such as narcissistic insult.
We can discuss that next week if
you like.
HOPELESSNESS AND SUICIDE:
Question: "I recently read
a psychological report in which the psychologist referred to the patient as
feeling “hopeless” and emphasized the importance of this emotion. I think
everyone feels hopeless at times and that this is not particularly
important. I would appreciate your comments."
Dr. Adams Responds: While
most of us will feel helpless at times, and many of us will describe a
particular situation as hopeless, few of us will see our life itself as
hopeless.
Hopelessness in this context
involves several major aspects, among those are:
a.
Fear of the future
b.
Negative future expectancy
In these cases, the future is
something to avoid. The future is something that is either menacing or
offers no salvation. The future will only make matters worse and is to be
avoided.
When we are in desperate
situations, that which “gets us through” is the concept of hope:
1.
hope that things will change
2.
hope that other options will emerge
3.
hope that others will intervene
Without the concept of hope, the
individual feels futile, threatened and ultimately defeated.
Depressed individuals can
perceive (often inaccurately) that they are helpless. But when they truly
believe that their situation has become hopeless, the reasons for survival
begin to vanish.
Hopelessness is found in suicidal
individuals:
They have resolved that their
future is without option, without optimism and without potential. Their
continuing to exist is a burden to themselves and others. Their feeling of
hopelessness may be the foundation of an attempt to take their own life.
The psychologist who notes that a
patient has begin to experience hopelessness is well founded in concern that
the patient may have become a danger to themselves.
THE CONCEPT OF
"PATHOPLASTICITY":
Question: "In one of your
recent lectures, you mentioned that injured workers are difficult to treat
because of something called "pathoplasticity." You said that because of this
pathoplasticity, it would be difficult to determine a patient's goals and
needs without psychologically evaluating them. What does pathoplasticity
mean and how does it effect my cases?"
Dr. Adams Responds:
Regardless of what illness or injury we have incurred, no two of us appear
to respond the same to almost identical situations.
When we have the flu, or a
sprained ankle, or a bruised knee, we have different levels of alarm,
concern, expectancy and different ways of responding, varying from mild
concern to extreme disappointment.
Equally important, we are
different individuals with different levels of tolerance for pain,
suffering, inconvenience, fear, apprehension and compliance.
We cannot depend upon a physical
diagnosis to tell us what the patient "wants and plans to do." One patient
with carpal tunnel syndrome may have been ready for a career change while
another may feel that this limitation is a major burden.
We cannot depend upon a physical
diagnosis to tell us what the patient expects from care. One patient with a
lumbar strain may anticipate that oral medication and limited bed rest will
ameliorate all discomfort while another may realize that he/she is grossly
de-conditioned, sedentary and needs to comply consistently, putting forth
maximum effort in physical therapies.
We cannot depend upon a physical
diagnosis to tell us what impact the patient's economic, educational, and
interpersonal history has upon his/her desire and willingness to mobilize.
One patient may be 46 and worked since she was 16 and see the limitations as
a justification for finally having others care for her. Another may feel
that limitations limit his male image and that he must resolve this or be
seen as weak and ineffectual by his peer group...or his wife.
Since the SAME injury, can
express itself DIFFERENTLY in EACH person, we simply need a better
psychological understanding of each patient.
THE CONCEPT OF DEPRESSION:
Question: "It appears that
just when we are about to return an employee to work, the issue of
"depression" arises as a reason for them not to return. What do I need to
know about depression and its validity?"
Dr. Adams Responds:
Depression is an affective or mood disorder. It is estimated that ~8% of the
general population suffers from depression at any given time.
Depression is not, itself, a
disabling condition.
It is characterized by a series
of psychological symptoms (sadness, irritability, hopelessness, despair) and
physical symptoms (sleep and appetite changes, inability to concentrate,
difficulty with decision making). The symptoms of depression may be tied to
a situational event and rapidly resolve, can emerge from physical (brain
chemistry) changes, and can be chronic and mild and related to a series of
ongoing losses.
Many believe that not working
contributes to the sense of helplessness that feeds depression.
Unquestionably, becoming financially dependent and nonproductive does little
to resolve the diminished feelings of self-worth that accompany depression.
Psychotherapy, in combination
with some of the newer medications, have been shown to be an impressive
combination for rapid improvement or relief from depression.
In summary, depression is most
often an easily treatment and infrequently disabling condition. Some believe
that depression is a normal response of our bodies to the stressors placed
upon them. Resolution, not rest, is the solution for the problem.
THE CAUSES OF PROCRASTINATION:
Question:
"I am likely no different than many of the cases for whom
I am responsible, I seem to put off a great many things. This, I know, is
not productive, but I do not really know why I do it. Assistance would be
appreciated."
Dr. Adams Responds: Your
capacity to oppose the will of others is a crucial part of your
development…but only as a child. It is the normal process of separating from
adult rule and assuming personal responsibility.
In adulthood, however, behaviors
such as obstinacy, procrastination, disobedience, carelessness, negativism,
dawdling, provocation, resistance to change and blocking communication from
others, are ways of expressing anger and resentment. Importantly, the
chronic indirect expression of anger, in these ways, is obviously
self-destructive since it disrupts relationships, interferes with
productivity, and places one at risk for failure.
