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Delayed recovery: Taking another look.

Delayed Recovery: Taking Another Look

There is a plethora of terminology which deals with the general issue of injured workers (and those receiving other forms of compensation) not returning to work within an appropriate time period. Proper use of such terminology as "delayed recovery", "compensation neurosis", and "functional overlay" are not clear. Guidelines may be sifted out from the statistics available on low back pain, for which there are numerous references. For example, Raj (1986) cites "general agreement" that 80-90 percent of low back pain improves in two months regardless of treatment with 99.5 percent avoiding back surgery (p.15). For some, (Greenwood, 1984) a critical period of 6-12 weeks post injury becomes an indication of the "problem cases," while for others (Raj, 1986) six months is a statistical marker.

Several sources identify both "delayed recovery" and "malingering" as rare. (Derebery & Tullis, 1983; Ross, 1977; Woodyard, 1982). Statistics provided by the Department of Labor and Industry in Minnesota reveal that 95 percent of injured workers have returned to work in one year, and that the remaining five percent constitute a major drain on the compensation system. Furthermore, the five percent for whom prolonged disability is a major concern are not those who receive more income by remaining at home but, rather, represent the majority of injured workers who suffer significant financial hardship through low wage replacement, compounded by loss of medical insurance, pensions and other benefits. (Mn. Dept. Labor & Industry, 1988). The relationship between delayed recovery and compensation is not linear, as some earlier information had suggested (Beals, 1984).

To suggest that the issue of "delayed recovery" is simply a matter of time is too simplistic. And looking at delayed recovery as an issue of an individual's personality or unconscious struggle has had little effect on decreasing the magnitude of the problem. The purpose of this article is to review the factors which have been ascribed as contributing factors in delayed recovery and to suggest that delayed recovery be examined as a biopsychosocial issue.

Conflicting Terminology

The use of several terms, rather than a single diagnostic category, would also appear to reflect our difficulty in categorizing the behavior of "undue delay in returning to work" in terms of an individual's traits.

Derebery and Tullis (1983) suggest that there is no one appropriate DSM - III category for this behavior and that it is inclusive of the following categories (p. 831):

* 300.81 Somatiform

* 300.11 Conversion type hysterical neurosis

* 307.80 Psychogenic

* 300.70 Hypochondriasis

* 316.00 Psychological factors affecting physical

condition

More recent efforts have been made in categorizing the "compensation neurosis" profile (Fishbain et al., 1988; Mendelson, 1984). Some of the difficulty in defining a specific entity may stem from the involvement of the legal system, worker's compensation, and various political factors, rather than it being simply a biomedical issue. In 1962 Manning (a psychiatrist) stated:

"Disability is not a definable entity but is a summation of a variety of factors: medical, psychological, and sociological. Disability is a subjective human reaction to forces, real or potential, acting upon the individual. Therefore, disability simply cannot be described or evaluated in the same terms as illness or injury." (Lerner, 1971)

This definition appears contrary to others (Rossman, 1984) which define disease as an observable pathologic change in organic function or form and illness represents the experience and personal meaning of the problem. Lerner (1971) suggests that "disability" in the industrial and legal area specifically and concretely applies to the loss of function resulting from disease or injury (p. 48). The term "neurosis" appears to be coined from Freudian theories regarding neuroses-- an unconscious process where some "secondary gain" is great enough to maintain the condition-- following injury, these are usually pain complaints (Robitscher, 1971). He adds that coinage of "compensation neurosis" was initially a legal tactic attempting to remove responsibility from the injured worker by declaring it separate from malingering which is a conscious feigning of pain complaints, to identify the suffering as real, to legitimatize it as a disease rather than a sin and therefore worthy of medical treatment as is any other disease.

Use of such classification effectively identifies that psychological and physical issues are involved, with the psychological issues appearing to perpetuate the physical complaints, and that the compensation system is accountable. Since the general precedence of the workers' compensation system is that a worker is taken "as is" with any prior susceptibilities the legal stance for financial accountability by the employer has been seemingly well established. (Robitscher, 1971; Trice & Roman, 1971). Efforts to deal with delayed recovery by setting "Maximal Medical Improvement" (MMI) and therefore limiting funds to these individuals appears to be underway in a number of states. These new restrictions are attempts to set limits on the employers' responsibilities for work-related injuries. Although this goal of altering financial accountability for injured workers not returning to work may be successful, it does not address the basic issue that some individuals, following an injury, have difficulty returning to work. And while it had been projected in the past that the finalizing of compensation or litigation claims produced instant "cures" (Weighill, 1983; Dworkin et al., 1985) there is increasing evidence that this is not the case. The "greenback poultice" as it has been described is no longer considered to be effective in the majority of cases (Mersky, 1986). A study by Encel and Johnson (in Weighill, 1978/1983) reports that low back injuries have long-range effects on the type, difficulty and wages of jobs and that few regained pre-injury employment status. Woodyard (1982) confirms that few low back injuries return to previous levels of employment.

Labeling the Behavior

If it cannot be truly considered a compensation neurosis in light of the above, then we might also look at the nature of the presumed secondary gains and challenge the alleged benefits of the behavior to appropriately maintain the "neurotic" component of the terminology. Upon close examination, it is often difficult to see sufficient gains that offset the losses. Many of the gains have been identified as immature ones, i.e., unmet dependency needs, anger or retaliation against the employer, but these seem trivial compared to identified losses, which include role losses, self-esteem, adult citizenship and often enormous financial losses (Talkington, 1971; Ross, 1977).

Some additional factors which trigger the "compensation neurosis" have been identified as: unconscious psychological conflicts; personal predisposition; pre-existing psychological disability; low work satisfaction; poor attitudes toward work and social responsibilities; family system homeostasis under threat; the accident as a "solution" to current life problems; no incentive for light duty; unions encouraging additional time off, and others (Weighill, 1983; Hanson-Mayer, 1984).

Contributing factors in delayed recovery are those which pre-existed the time of the injury, factors arising with the injury, and factors arising after the injury (Enelow 1971; Tuck, 1983).

Some workers' compensation systems are recognizing the role of these various factors in delayed recovery and assisting in earlier intervention (Mn. Dept. Labor & Industry, Health Care Providers Guide). While most of the factors which have been previously identified are individual ones, recent research is beginning to identify the disability following injury as being affected by external economic factors (Volinn et al., 1988), in some cases directly reflecting an increase in stress due to the economy prior to the injury.

One can begin to see that delayed recovery is an interactive process. There have yet to be identified any personality cluster which, when subjected to an injury, produces delayed recovery. Hence "A" + Injury = Delayed Recovery is too simplistic a formula by which we could identify or intervene to decrease undesirable behavior. The scenario which is beginning to emerge is one of an individual, at some period of increased stress and/or vulnerability and confronted with a cluster of external forces, is injured, and all these factors interact in a manner which reduces the likelihood of rapid recovery. With "a" being the internal cluster, and "x" being the environmental factors, "a" + "x" + injury = delayed recovery. This presents the need for new considerations regarding treatment of individuals, and a biopsychosocial approach to delayed recovery as a process. A specific lack of certain coping skills, when combined with physical aspects of pain which are often unclear, and combined with social, industrial and medical factors reiterate the complexity of Delayed Recovery Syndrome. The factors identified in Figure 2 may represent only a "window" into the still greater complexities yet unidentified.

A New Model

Both treatment and prevention according to a biopsychosocial model are difficult for health professionals. It is not, in accordance with their training, a reductionist model, i.e., it does not find answers by analyzing and narrowing one's focus. Rather, it is a model of synthesis which, at best, leaves one with the alternative of making changes in a process rather than prescribing a specific treatment to effect a "cure." Biopsychosocial models can seldom be changed by one individual carrying out a prescribed treatment without regard for the entire process. And neither our medical nor our legal systems, currently based on either diagnoses or reimbursement, is geared for changing a complex process. A sketch of a biopsychosocial model, as shown in Figure 3, identifies readily the numerous changes which need to occur for a biopsychosocial model to be effective.

Delayed recovery is not due solely to health impairment, including both physical and psychological. Other issues which need to be considered include: labor market conditions, area economic characteristics, work environments, educational levels, household factors and cultural values (Greenwood, 1984). This is a quantum leap from the simplistic view of "compensation neurosis" being a by-product of hostility and unmet dependency needs, but it is not to deny the possibility that these may be factors in the "cluster." Factors inherent in certain individuals must be included and recent research (Volinn et al., 1988) is suggesting that an individual's susceptibility to delayed recovery following injury may be in part due to the general economic conditions. These external economic factors exist prior to and following the injury just as do other personal factors such as coping skills, ability to adapt, skills in communicating psychological needs, and inherent sense of control over major life events such as functional loss and persistent pain.

Not only must treatment change with our cultural beliefs and values regarding "illness" and "responsibility to work", but the more difficult issue of prevention of Delayed Recovery Syndrome must foresee these changes and adapt new techniques which are not supported with scientific data. The biopsychosocial model of prevention shown in Figure 4 represents a sense of what would have reduced the current biopsychosocial issues of delayed recovery. These models must necessarily include a visionary sense of the future needs.

And when the values, beliefs, and attitudes of the working class-- those generally caught up in the workers' compensation system-- are examined closely, they bear little resemblance to those of the health professionals, generally white, upper middle class, who treat them. These individuals generally lack "psychological insight"-- as defined by the health professionals-- but it is a cultural issue that is lifelong rather than a peculiar personality characteristic. They simply problem-solve and cope very differently than those caring for them (Rubin, 1976). And classes within a social strata may vary considerably in the cultural message regarding the work ethic (Tuck, 1983). Combine these discrepancies in methods of coping following injury with the cultural messages which become pertinent following an injury and one can see the enormous conflicts which arise. Double binds become constant sources of conflict.

A major double bind arises during the vague transition period from "acute" to "chronic" pain. In a society which is at best uncomfortable with chronic pain, patients frequently report feeling trapped by mixed messages and an inability to meet their own needs and others' expectations. Such double binds as are included in Figure 5 are particularly confusing when both extremes are presented within a family, a business, or a circle of close friends.

Individuals who are identified as falling within the delayed recovery syndrome feel trapped not only by cultural misperceptions and by the vigor with which they are "blamed" for their delayed recovery, but they are overwhelmed by their losses in making choices for themselves. These individuals are often seeking a sense of having control and choices in their own future. Their attempts to negotiate, however, are often perceived as resistance by health professionals and the additional stress frequently increases the individual's pain complaints.

We are a society of somaticizers. It is little wonder that conflicts presented by the losses, the double-binds and the adversarial nature of the workers' compensation system result in an increase in somatic complaints. Fifty to 75 percent of visits to a general practitioner are for psychosocial reasons which are reported as somatic complaints (Rossman, 1984). A position of uncertainty, decreased self-esteem, physical losses and double binds may contribute significantly to increased hopelessness and learned helplessness (Seligman, 1975) and any somatic complaints are likely to be exacerbated.

Injuries cost the employers money; it cost the employee losses in capabilities and opportunities. With conflicting messages, and numerous double-binds, individuals may begin to rigidly defend their position of inability because anything else appears unattainable. At the same time that we believe the injured worker has a "responsibility" to return to work and decrease health/compensation costs, our society believes they should be "adequately compensated" if harmed. In an era of lawsuits to address even simple grievances, it is difficult to expect someone deprived of wage-earning power and feeling damaged physically to not have their grievances addressed. And in our culture, grievances are frequently settled financially.

Lawsuits, it has been suggested, may be avoided by allowing the "victim" to express all their grievances. It has been suggested that much of the chronic pain syndrome can arise from iatrogenic disability inflicted by the health professionals immediately after the injury (Gildenberg, 1985; Haddod, 1987). If these individuals are allowed to verbalize their emotional turmoil to a compassionate professional early, many patients may well be able to cope with the injury better and recover more rapidly. Expression of these feelings may lead to a much needed catharsis (Keiser, 1971). It speaks strongly of the philosophy of our health care delivery system that is uses psychological services as a last resort, when the patient is finally encouraged to verbalize their frustrations and anger.

The emphasis in our current system is put on an individual's limitations, and the greater they are measured to be by our biomedical approach, the more the individual is "worth," and the more valid are their complaints (Hanson- Mayer, 1984). Validating not only their physical complaints ("We know the pain is real, even if we cannot pinpoint the cause.") but their psychosocial issues is a way of helping an individual "get on." Existential questions-- "Why me?" "Why do I have to lose everything I've worked for?"-- need to be addressed. While there are no "correct" answers, having dealt with the issues and the basic principle of "Life may not always be fair" to any one individual's satisfaction at least allows them to put it aside and move on. Allowing each individual to reach a conclusion, i.e., "Life is unfair", "This happened to me for a reason; even with my losses, I'm stronger" reclaims enormous amounts of energy for other consumption and may discharge repressed anger that was contributing to immobilization. Just as in cancer remissions, where the exceptional patient is studied, it might benefit us to examine those who work despite their pain, their losses, and their suffering. From those who have succeeded we may learn to help those who have seemingly failed. For both groups have pain but in one group their suffering of their pain is disabling and they are "stuck", while the others have certain coping skills, and an ability to adapt helps them "go on."

On an individual level, that may be all we can do, and it may be enough to "get on." But delayed recovery is much more than an individual issue-- it is a dilemma of our society. The paradox is to provide a needed social service and still maintain an individual's sense of responsibility for his or her own welfare (Brill, 1971,). Americans have come to expect payment from social institutions when their lives are disrupted, and the injured are encouraged by the medical model to adopt the "sick role" and by friends to "get all they can" (Keiser, 1971). This is not a strong position for active rehabilitation; providing passive therapies encourages passive "you fix it" attitudes (Meisler, 1971). Treatment of the problem rather than the symptoms would lead to decreased occurrence of the problem by mere increased awareness. Rehabilitation directed toward the behavior of delayed recovery which includes understanding it on an individual and biopsychosocial level facilitates problem-solving, active rehabilitation, vocational placement and resumption by the individual for their responsibility in the process.

Biopsychosocial models are also constructed so that the awareness and thus potential exists that some of the other stumbling blocks can be eliminated. By altering social and cultural attitudes, for example, potential clusters of factors which interact in another susceptible individual are eliminated. We have then not only accomplished a satisfactory prescription for treatment, but we have set up the environment for new potential outcomes. Biopsychosocial models are effective in demonstrating that if one domino is removed from the chain, the outcome changes. But biopsychosocial models make apparent that change cannot be accomplished by one individual. The inherent weakness of a biopsychosocial model is that few individuals are going to get an opportunity to singularly effect change. And much of what we measure our worth to be is a product of what we can each determine we have done. Producing change in delayed recovery may require not only broadening our view as a health professional, but also as individuals.

Summary

Delayed recovery is an issue for which a new perspective appears to be emerging. Previously viewed as an individual issue of non-compliance in returning to work, other factors are now seen as interacting with certain individuals to produce factors delaying recovery. A broader perspective, involving a biopsychosocial approach, appears consistent with recent literature citing the interactive forces which hinder returning to work. The biopsychosocial model can be used to examine more appropriate treatment options and directions for educational thrusts and effective prevention.
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Article Details
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Author:Headley, Barbara J.
Publication:The Journal of Rehabilitation
Date:Jul 1, 1989
Words:3049
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