Decidedly few injured workers can benefit from psychotherapy. This can be caused by cultural, intellectual, educational and social factors. Most injuries occur to those working semi-skilled, labor positions. The educational background is not conducive to their understanding the benefits of such care or regimenting themselves to complying with such care.

More importantly, many injuries occur with patients who are alexithymic (this means that they do not readily put their feelings into words). Such individuals often act upon their emotions rather than discuss them.

But arguably the reason that most injured workers will not benefit from psychological care is the cultural factors. Psychological problems, and by extension, psychological care, are seen as weaknesses. Quite often when an injured worker is asked if their parents suffered from psychological problems, the reply is "Naw, they were pretty strong people." Yet these same patients, when asked if their parents had ever had an addictive disorder, will readily acknowledge addiction in parents, sibs, extended family and self.

Secondly: by contrast most often the patient, the family, the case manager, the employer and the primary physician benefit from the patient being psychologically examined. It is only through psychological examination that the most critical patient care aspects can be determined. The psychological examination can determine:

Does this patient plan to return to work? We often operate as though this is a given. The person is physically capable of alternate work, such work may be available, the patient has family financial responsibilities, and the patient is years from retirement age. Nonetheless, a significant number of patients, for complex psychological reasons will elect not to return to work or not to return to that employer.

Do we fully understand how this injury occurred? Psychological examination quite often reveals that the patient harbors anger and resentment not only for the context in which the injury occurred but how the injury’s aftermath was managed, both by health care and by the employer. While these patient responses are instrumental in determining their willingness to participate in recovery, the patient rarely shares them with other than family. The patient does share them in psychological examination.

Does the patient truly understand the nature of the physical problem? I have been impressed over the last two decades with how little patient education occurs and/or how little of that information is incorporated by the patient. Whether due to intellectual or educational differences or, more likely, due to anxiety when being told, the patient rarely understands the true objective findings and what can, and what cannot be done to assist them.

How much of an issue is medication in these cases? Often the single greatest problem is the use, misuse, abuse and poor understanding of medications by patient, family and sometimes providers. Mood and sleep disorders can arise from medications given. Then other medications are given to treat the disorders caused by the first medications. Also, regardless of the prescription, the patient simply does not understand and will self-medicate. When a history of addiction exists, this problem is compounded.

How much of an issue is distrust and suspicion? One of the greatest emotional events following an injury is the perception that no one cares, that cost containment is the sole concern, that the providers are chosen based upon conservatism and that there must be a fight to secure effective care.