December 25, 2000

The Role of the Spouse in Disability 

Question:  "As a case manager, I feel that the single patient fares more poorly than the married injured worker. It seems to me that the availability of a husband or wife insures that the patient recovers more quickly?"   

Dr. Adams responds: "I wish that were true, but quite often it is not. The husband or wife of an injured worker may place oppressive financial pressure upon the patient. He/she may continue to spend and demand that the injured worker support such spending even though income is drastically reduced. 

The spouse may have long harbored resentment and use the timeframe of the injury as a convenient opportunity to emotionally and physically abandon the patient.  

There are several things to consider:

1. If the injured worker states he/she is depressed, is the spouse's demands or emotional abandonment the chief source of the depression

2. Has the spouse made the financial shortfall that much more difficult to tolerate

3. Is the spouse using guilt as a means of punishing and controlling the injured mate

4. Does the spouse foster disability as a means of now becoming the strength of the family 

I have frequently seen a husband or wife use the time period of an injury as a convenient time to activate an ongoing extramarital affair and actually abandon the patient when he/she is most vulnerable...or remain with the patient only to insure their split of any cash settlement.  

This is a complex issue that needs to be fully understood for its uniqueness in each case of work-related injury."

December 18, 2000

Medication Concerns 

Question:  "What concerns should I have about the medicating of an injured worker?"   

Dr. Adams responds: "Many. There are, however, four major areas of concern.

1.    Is the patient inadequately medicated and, therefore, is in such pain that all attempts to chart a path for a future becomes blocked by the discomfort that he/she is unable to tolerate?

2.    Is the patient overly-medicated so that there days are filled with adverse side effects including somnolence, nausea, dizziness and/or disorientation?

3.    Is the patient appropriately medicated for the true problem or are they medicated for sleep when the problem is depression or medicated for pain when the problem is anxiety.

4.    Is the medication itself giving rise to psychological complaints such as agitation, irritability, restlessness, alterations of mood, apprehension and even mild hallucinations? 

Quite often we have very inadequate histories on these patients. We do know whether they are capable of, or willing to, take their medication as prescribed. We do not know if they are reliant upon other family members to titrate their medication. 

Not infrequently, lack of timely approval for medication results in either delayed initiation of a needed medication or delay in timely refill of approved medication. 

December 11, 2000

The Holiday Crisis Among Patients 

Question:  "Do you believe that there is a crisis in cases of work-related injury tied to a time of the year?"   

Dr. Adams responds: “Yes, unquestionably as we approach the holiday season where the patient feels increased financial pressure, and concurrently often less access to their doctors, there is increased agitation.  

Benefit checks mailed during this time period may arrive late. Vacation scheduled may interfere with adjustor or nurse case manager availability. Pharmacy hours may complicate receipt of medication especially in those instances wherein medication is mailed (and/or prescriptions are to be called in when practices are all-but-chaotic due to before-the-holiday demand. 

I consulted on a case recently in which the injured (husband) was already deeply in debt with no means of generating income at this time. His wife, however, insists that he take out a loan, he cannot repay, in order to buy her Christmas presents. She is unable to fathom that this compounds their problem. Additionally, despite his lumbar, cervical and rotator cuff injuries, she feels he can return to laying foundation blocks. 

This is the time of the year when many patients are referred to me because they are `depressed about their pain’, but I learn that the underlying problem is fear and helplessness during the most economically demanding time of the year."

December 4, 2000

Phases and Stages of Injury

Question:  "What has been your experience regarding critical stages in the recovery process of back injured patients?" 

Dr. Adams responds: "Assuming that this is not a surgical case, that it is a case of sprain/strain with perhaps underlying degenerative disk disease, the first three months following injury are critical.

It is during the first three months that the patient begins to understand the injury, the impact of medication, physical therapy and other conservative measures and begins to assess options and alternatives with regard to work and personal life.

If, however, this is a period complicated by several changes of providers, patients seeking narcotic analgesia and economic/interpersonal problems arising in the home, the patient may become focused and fixed upon his/her own perceptions of limitations. These perceptions may lead to the chronicity that follows.

By the end of a year, the patient has increased financial need but often decreased personal urgency to return to employment. Weight gains, daytime napping, and lack of a schedule begin to take their toll.

By the end of 18-24 months, the patient may have become fixed in an erroneous perception of total disability. Plans have dissolved and the only focus is a combination of pain, frustration and concepts of financial restitution. The latter can become dominant and because of the patient’s own lack of attempts to mobilize, he/she begins to attach unrealistic financial value to their injury.

This, in turn, may lead to the 24+ month period in which the patient has learned to languish, no longer perceives that return to work is forthcoming (even in quite young patients) and their spouses have gone to work or begun to work more hours).

I have often said that the first 3-6 months are critical. That is the timeframe in which you should determine what the injury means to the patient and how he/she perceives the future and his/her own goals."

November 27, 2000

Highest Risk/Lowest Return to Work 

Question:  "From a psychological perspective, are there occupations that represent the lowest probability of return to work?"   

Dr. Adams responds: "Many construction workers quit high school due to a combination of readily available income in the construction industry combined with continually changing work environments. That is, they are not “tied to a desk,” they see the fruits of their labor, they often earn more than their high school educated friends, and there is constant stimulation. 

However, due to the nature of their work, they are more prone to lifting injuries, falls, and severe lacerations.  

Once injured, especially if they are well into adulthood, lack a GED, lack specific alternate occupational interests, they have few employment options if they have lifting (and/or other) restrictions. 

They become readily frightened, discouraged, and irritable. While they may truly be clinically depressed, they label depression as a “weakness.” They will tend to express their concerns as anger, and the anger often drives off those upon whom they must now rely…their spouse, their friends, their doctors and their case managers.  

The most common complaint of injured construction workers is `I never considered doing anything else…I do not know other trades…I have no other interests…I am already in debt…(and) I have no options.' 

The highest risk for depression and poor problem solving appears to arise in those in the construction industry, especially those whose lives were characterized by expenditures equal to, or exceeding, income and who can verbalize no alternate work interests."

November 20, 2000

Critical Stages and Critical Ages for Injury 

Question:  "From a psychological perspective, are there ages of life or stages of life in which injury is better handled and ages at which it is more poorly tolerated."   

Dr. Adams responds: “A woman who dropped out of school at 16, worked out of necessity to support her children, has always performed repetitive and semi-skilled positions, and is now middle-aged with chronic, even mild, residual pain, is less likely to return to work.  Her children are grown, she has grandchildren, and she has sufficient spousal income to support their household. This may be the only stage of her life where she believes she has remaining youth and access to (grand) child rearing. With regrets, and out of necessity, she missed much of her own youth, and she now perceives that her injury enables her to have some semblance of the life she has never had. 

From the opposite prospective is the high school educated male who had plans of future academic training, whether tech school or even college. He has now been injured in his early 20s, he has several small children, and daycare expenses have always prohibited his wife from working. Now, he is unable to see how he, alone, can build a viable future or what options remain. He becomes self-pitying, gains weight, sleeps much of the day away and is irritable and undermining of what little his has left…his family. His wife may begin working, and he remains at home “caring” for the children.  

In between those extremes are the complexities posed by an injured worker who finds that his/her net cash benefits from workers’ compensation, when combined with society security funds, may exceed that which was generated when the patient was employed. This may especially be true if the individual had seasonal work. Workers’ compensation, at a minimum, may represent a consistency of income that the household has not previously seen. In some case, it “pays more” to be injured than to be working. 

November 13, 2000

This Week's Topic: Using Narcissism to Mobilize the Patient 

Question:  "I am working with a patient who is so self-involved that I truly believe she enjoys her painful injury. She smiles and laughs about her complaints, and her family hovers about her, making it impossible to mobilize her."   

Dr. Adams responds: "Narcissistic people crave attention and acclaim. They wish to be the center of attention and want to be seen as unique, gifted and special. 

When such individuals are injured, they can become deeply entrenched in the attention, affection and praise provided by the family. 

There is, however, a way to approach and potentially resolve this problem: 

a. Be certain that the personality disorder (often called an Axis II Disorder), a developmental defect, has been accurately diagnosed

b. Have someone see the patient who can communicate that true uniqueness does not reside in being helpless and dependent but resides in the admiration for mobilizing and becoming productive

c. Insure that the employer verbally rewards the patient's return to productivity

d. Have someone (or yourself) explain to the family that if the patient is rewarded for non-productivity, he/she will remain non-productive

e. Be certain that the primary provider responds positively (as does physical therapy) to any independent and mobilizing behavior 

Your experience is not unique. Most case workers find that narcissistic patients learn to revel in the attention from their complaints. Be certain that they see someone who redirects them to be more invested in their productivity."

November 6, 2000

This Week's Topic: Lost Body Parts – Impact of Amputation?

Question:  "I do not routinely request a psychological examination of a patient who has lost a body part…finger, leg, arm, but you feel that it is mandatory. Can you explain?" 

Dr. Adams responds: “It is clinically referred to as “body ego”, that concept we have of ourselves and how we adjust to change. The most ready example is how concerned we are when we our hair grays, our skin wrinkles and we gain weight with age. We look back at earlier photos and quite often feel a sense of loss of youth.

For the amputation victim, this is not a gradual process as would be hair loss. It is sudden, traumatic, and permanent. There are no facelifts, hair coloring or diet programs to compensate for this loss. Additionally, they may have “phantom limb” pain/itching or other sensations that force them to continually focus upon the loss. 

But clearly, life has changed for the amputation patient. He/she must accept the loss as permanent. For women, the loss of even the distal end of a finger is a cosmetic problem since nails are often a source of cosmetic importance. 

It is extremely important to determine if the amputation patient has begun to incorporate the loss. For many, it is a sense that the injury “could have been worse,” and the sense of loss is minor. For others, the loss will affect many areas of their lives and their own sense of self.

Order the exam.”

October 30, 2000

This Week's Topic: Assault Victims…and their recovery? 

Question:  "I refer a lot of workers whose injury is the result of assault either by coworker or by someone committing a robbery. They all seem to require at least an evaluation, but I wondered what is the greatest obstacle to their recovery."   

Dr. Adams responds: "In a word…husbands. 

Husbands are the single greatest obstacle to recovery. They often feel their wife being assaulted impugned their masculinity. They have mobilized great anger, which they cannot adequately discharge. They are often blameful of those who attempt to assist their wife. 

More importantly, since they cannot retaliate, they become overly, and pathologically nurturing. That is, they actually block the recovery process by reinforcing their wife’s dependency and fears. 

While the husbands may have actually grown weary of their wife’s fears, nightmares, avoidant behaviors and clinginess, the husbands express their anger indirectly by emphasizing and dwelling upon the trauma…and the husbands own anger over its occurrence.  

Compounding this is the fear of both husband and wife when the perpetrator has not been apprehended. They erroneously believe that perpetrators wish to “re-visit” their victims and harm them again. There are no data to support such a fear, but it is extremely common. 

I recommend that any time there is an assaulted female that her boyfriend or husband be clinically (briefly) interviewed at least once and reminded of his role in her recovery process."

October 23, 2000

This Week's Topic: How Much Counseling versus Psychotherapy? 

Question:  "I am an adjustor whose claimant needs some counseling. How much should be required and what does it involve?"  

Dr. Adams responds: Once again these are actually three entirely separate concepts. So let me address them in order: 

1.    Counseling occurs any time anyone assists another individual in decision- making or problem resolution. It entails recommendations, advice and information. It is not a mental health procedure; it is merely the interaction between two people. Thus, I strongly suspect you are actually asking about psychotherapy. 

2.    Psychotherapy is a psychological procedure in which the needs, drives, motivation, and goals of the patient are explored and revealed. Often the patient is largely unaware of the factors that are operating. Problems are confounded within distorted perceptions.   

In the past 75 years, over 100 forms of psychotherapy emerged as theories of personality development and function have been refined. The one with which you would be most familiar is psychoanalytic psychotherapy which deals with unconscious, and often sexual, drives which have become distorted, repressed and/or denied.

However, in recent years the chief focus of psychotherapy has been on cognitive-behavior psychotherapy in which the patient is assisted in seeing the relationship between their beliefs and their behaviors, their distortion and their own role in their problems, and how each contributes to the other.

3.    Duration of care has greatly changed over the years. There was a time when a patient was seen 3-5 times per week literally for years. Today, most managed care organizations authorize 12-18 visits, and the preponderance of effective work can be achieved during that timeframe.

I always recommend that when a patient is authorized for psychotherapy that the adjustor or nurse case manager request a treatment plan and prognosis. I recommend that the patient is regularly re-evaluated for progress and a change of provider be implemented if the patient is not improving. There are many (perhaps the majority) of injured workers who do not readily benefit from psychotherapy because of educational and cultural differences (and stigma) attached to psychological care. I also recommend that the primary provider (most often a surgeon in these cases) be sent regular updates by the treating psychologist since progress (or absence thereof) can impact compliance with orthopedic care.

Studies indicate that injured workers whose subjective complaints exceed their objective orthopedic findings have psychological factors impacting the recovery process. For such patients, an evaluation for the viability and appropriateness of psychotherapy should be considered.

October 16, 2000

This Week's Topic: Disability Role Modeling? 

Question:  "Do you feel that disability runs in families? Do people inherit or learn the tendency for later disability?"   

Dr. Adams responds: Actually, those are two separate questions: 

1. Are there physical similarities between, for example, those who sustain low back injuries? 

The answer to this is an unqualified “yes.” There are genetic tendencies, within families, for the development of specific body types. Some body types are more often associated with predisposing vulnerability to certain types of injuries.  

Thus, a tall, slender father who has sustained a lumbar injury may, indeed, produce a tall slender son who is vulnerable to the same injury. 

Also, it is not unusual for descendants to engage in similar work as their parents. A mother who performed production work or a father who did construction work are more likely to produce children who work in similar vocations. They would be similarly vulnerable in high injury-risk occupations. 

2. But I suspect you were also asking whether there are families with disabled members who produce successive generations of disabled individuals. And, again, the answer is “yes.” 

A father disabled by the time he is 30 may well produce children who view disability as either an inevitable outcome of life…or certainly not an unusual outcome.  A child raised on workers’ compensation income, whose home was purchased by a workers’ compensation settlement, and whose same sex role-model was continually obtunded by pain is more likely to reproduce that pattern in a subsequent generation. 

One example that always comes to mind was a tall thin, male who had sustained a mild back injury but perceived himself as permanently disabled. His father and two brothers were both permanently disabled. He was twenty-two years of age. His father and brothers had been disabled before age twenty-eight. He tearfully stated that he had always hoped to lead a long and productive career in construction, “working until I was maybe even thirty.”

October 9, 2000

Erosion of the injured patient’s sexual role?

Question:  "I wonder if one of the sources of depression among injured workers is not the change in their sexual role. I wonder if prior to injury, most injured workers have a specific role and simply cannot adapt to the change."   

Dr. Adams responds: That is an excellent point, and sexual stereotypes are more common among those who do manual, production, and repetitive or semi-skilled work.  

They believe in very specific roles for males and females. 

The males often feel their sexuality has been impugned by their sudden reduction in income. Also, unable to engage in physical tasks, whether for productivity or leisure, suggests to them that they are somehow “less of a man” than they were prior to injury.  

For women, pain often makes them less sexually available or motivated, and they fear abandonment. Unable to remain active, like their male counterpart, they gain considerable weight, leading to a decreased sense of value or personal worth. 

The women, as we have noted before, often respond with expressions of helplessness and hopelessness, and the males respond with anger and resentment. Both are equally likely to abuse prescribed and other substances to deal with these emotions.  

While their focus initially is upon full recovery, as debt and family conflict mount, their focus becomes that of futility.  

Both injured males and injured females engage in counterproductive means of re-establishing their sexual identity. The females may become increasing passive and dependent. The males become negativistic and noncompliant as a means of exhibiting what they feel to be “strength.” 

The longer these factors operate before they are diagnosed, the more entrenched becomes the problem and the more resistant becomes the patient.  

October 2, 2000

It is important to intervene, and dispel where possible, the patient’s sense of betrayal mounting resentment.