Pitfalls in psychological injuries and how to optimise return to work

Pitfalls in Managing Psychological Injuries

Dr Josie Sundin

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Facilitator:

Hello and welcome to today's webinar. It's our encore webinar on Pitfalls in Managing Psychological Injuries. My name is Rachel Hawkins and I will be your facilitator for today. Next to me is Dr Josie Sundin, Psychiatrist and our expert presenter. She's back by popular demand. Before I hand over to Josie we have some tips on making the most of your webinar experience.

Firstly, Josie will present for approximately 40 minutes, at the end of the presentation there'll be an opportunity to answer your questions in a formal sense. Josie has also indicated that she is happy to take questions and answer those throughout, so if there's something that is bugging you or you wanted some more information on, please let us know and Josie will happy to flesh out any more information on a topic or answer your questions.

Also to encourage you to interact throughout the presentation we will ask poll questions. Again, a simple prompt will pop up on the right side of your screen and you will have a brief moment to respond.

Slide 3

I will now invite Josie to share her expertise on the most common work-related psychiatric disorders, tips on how you can help facilitate a sustained and return to work as well as some tips for successful rehabilitation and return to work on those accepted psychiatric claims.

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Dr Josie Sundin:

Thank you Rachel. It's delightful to be invited to come back again and speak to everybody.

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I'm going to be talking about a group of psychiatric conditions, but particularly trying to focus on the issues that might be problematic for you in trying to manage psychiatric conditions. So we're starting with the most common psychiatric condition you're likely to encounter which is the adjustment disorders. You'll see these would classify such as an adjustment disorder with anxiety, mixed anxiety and depressed mood, depressed mood or mixed disturbance of emotion and conduct.

These are conditions where you have a development of emotional or behavioural symptoms in response to the onset of a stressor. The important thing with regards to the diagnosis is that the psychological presentation is in excess of that which you'd expect and is producing social and occupational impairment.

It's also important to remember that the condition is expected to cease within six months of cessation of the stressor or of its consequences and I've underlined consequences because that's often one of the most difficult components for people managing claims because the worker may have left the workplace, or the physical injury may have been operated on but you've still got a claim in talking about psychological difficulties and that can be a point of frustration.

It is important to understand that with these conditions that it's not as severe as a major depressive order which we will come to a little bit later. Managing adjustment disorders can be particularly difficult to manage in situations where there's either been workplace bullying or harassment.

Actually, I'll just interrupt myself now. I think you've all been told that you will get these slides and my notes. So, please feel very free just to sit back, relax and listen to the talk, throw in questions any time you like, but you don't need to write anything down because you'll get all of the slides as we go along.

With the adjustment disorders, if there's been an environment of workplace bullying or harassment, you're going to see a worse outcome in terms of the adjustment disorder. If there's been an atmosphere that has sought to normalise the behaviour or a manager or supervisor has actively disregarded complaints over a period of time, this will increase the worker's sense of grievance and it is very difficult to get people beyond this even after they've left work if they feel not listened to or responded to.

It's also important to think about adjustment disorders as being in effect a secondary condition so they can arise not only out of interactive or dynamic situations within the workplace, but they will commonly be presented after physical injuries, and it's important within this context to understand that under our legislation that a claimant with a physical injury will not be compensated for pain, but they will certainly be compensated for the emotional distress and frustration that arises out of the incapacity if they develop a full psychological/psychiatric condition.

One of the most important things and I always seek to emphasise to people is to understand that if you could see me now I'm holding up my hands and pointing out that anxiety and anger are flipsides of the same coin. They're both driven by adrenaline and they're going to be manifested differently according to a person's gender, cultural experience, inclination, personality style. So it's quite common that you'll encounter a worker who's somewhat intransigent or angry, and if you stop back and reflect on it you'll come to understand that it may very well be that this is a very anxious worker. So if you use all of your skills that go into managing anxiety and support and give that person a sense that they're being listened to, that will work very well at assisting them to ease back a bit. They'll be less aggressive, less difficult to manage and everyone's going to be happier in terms of the outcomes.

The other thing that I think is relevant when it comes to adjustment disorders is to be aware of managing both your own expectations and the expectations of others around you. What can seem to one person a very minor incident can be a major incident for another. We talk in the compensation world about the concept of the egg shell skull. That's an old concept in law that refers to the individual who may take a blow to the head which would only cause a minor concussion to one individual but a fracture in another. The same thing is true when it comes to psychological conditions. People bring themselves and their past histories to the workplace and while some of those personality experiences may be very, very valuable in a worker, it can also sometimes be a difficulty when it comes to managing a difficult claim.

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The next step up from an adjustment disorder with depressed mood is a major depressive disorder. This is the biological condition which is characterised by quite well-defined changes in what we call the neuro-vegetative function – sleep, appetite, energy and motivation. I've listened to myself saying – I'm using the word "important", "important", over and over. So, please excuse my repetitious language, but it is important to understand in the major depressive disorder that these people actually have disturbance of function in the prefrontal lobes of their brain. This is the part of the brain that's all about organisation, planning, foreseeing consequences, motivation. So you can, I'm sure readily understand that if you've got a person where that part of their brain is under-functioning, then they're going to have great difficulty handling, for example the paperwork and the emails that are all part of a claim.

I've often thought it's one of the ironies and great difficulties in managing a patient that I'm seeing who's got a major depressive disorder because when they're least able to handle paperwork they're expected to handle the most paperwork. So any assistance that can be given, any appreciation that's given to the fact that these people might be slower, they might need assistance, they might need either you to directly assist them or to identify a person who can assist them, is going to create a good atmosphere in terms of the management of the claim and make them less anxious and will ultimately aid their recovery.

A common features of major depressive disorders is that individuals with this condition will suffer what we call a diurnal mood variation and most commonly this means that they're absolutely terrible first thing in the morning. They're slow, they've often had a bad night's sleep. So they find it hard to get started but their mood state and their cognitive function will improve towards the end of the day. So if you're needing to interact with a worker who's got a major depressive disorder, I often recommend that it's a good idea to try and make sure that you plan your meetings, plan your contacts, later in the day.

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Post Traumatic Stress Disorder, a condition very common in particular types of industries, such as police officers, ambulance officers, paramedics and increasingly amongst nurses and we're even seeing claims from staff generally in hospital. It takes into account the concept not only of direct experience of a traumatic event, but also the concept of what we call vicarious traumatisation.

So, if you have an administrative officer who's working say, with the Police or with the Ambulance Department collating photographs of murders or accident scenes, that individual, whilst they're not directly exposed to the trauma, can indeed actually develop Post Traumatic Stress Disorder from having to deal with such vivid and unpleasant graphic imagery. So, if you get a case like that don't automatically think that this is a person who is overdoing it or exaggerating it.

The diagnosis of Post Traumatic Stress Disorder in the world of psychiatry has been a bit of a moveable feast over the years. We did very badly around World War One where psychiatry and medicine in general tended to ignore it. There are those who argue these days that the definition is getting a little bit too loose, but it does still incorporate learning of a traumatic event involving a close family member or a close friend. It is not enough to hear about a workmate 300 kilometres away who's been injured. It has to be a close family member or close friend. I find in my own practice that PTSD tends to be a little bit over-diagnosed and commonly there'll be a crossover with an adjustment disorder with anxiety or mixed anxiety and depressed mood. It's really I'm looking for the severity of the stressor and the psychological consequences that flow from that and we'll talk about those in just a moment.

One other little element – sorry, Rachel's telling me that…

Facilitator:                                

Hi Josie. We just have a question come through while we're talking about the diagnosis of PTSD, so I'm sorry to interrupt but I thought it was timely and it's just specifically with regards to GPs diagnosing PTSD and how soon after the work-related event can it be diagnosed?

Dr Josie Sundin:

Thanks very much for that question. Post Traumatic Stress Disorder isn't diagnosed in the immediate aftermath of a trauma. If you have a person – and we might just go onto the next slide to give you an idea of the symptomology

.Slide 8

There you go. Sorry, I'm trying to do the slides as well as speak and I'm not terribly technically wizard. In the first instance after an event, the most likely diagnosis is going to be an acute stress disorder. If you've got a person who's demonstrating symptoms around re-experiencing phenomena, avoidance, flashbacks and physiological arousal, if the person who's presenting has still got symptoms more than six weeks after the event or doesn't develop symptoms for a number of months after the traumatic event, then we're going to move to a diagnosis of Post Traumatic Stress Disorder.

Now, perhaps we can, in a classification world be criticised for saying "Well, why do you separate those two out?" It's very simple. A lot of people will go through quite traumatic events but with the support of family friends, a good employer, a good HR person, they won't actually go on to develop a fulminant PTSD and I rather like to know that because it gives me hope that there are some interventions and some things that can be done by all of us to make sure that people don't go on to have what can be a chronic condition.

I just want to mention one thing for those of you who do have to work in some of the industries such as Police or Ambulance officers, be aware that some workplace cultures will discourage the acknowledgement of emotional problems. We talk about the concept of siege mentality and there's a famous old quote which I think runs to the lines of "If you're not with me, you're against me," and that really sums up siege mentality. For frontline officers the sense that only those on their side of the wall support them and are there to help them becomes very important. Anyone who starts to show a sense of weakness or any kind of emotional vulnerability, those individuals can very rapidly be isolated and alienated within the workplace environment and if that happens, that's then going to aggravate the PTSD.

Certainly these types of industries are improving. They're certainly making a better effort. I've been involved with psychiatry for 30 years now. I can tell you the Police in particular are getting much better at looking after their officers, but it's still not ideal. So for those of you who are managing these cases you do need to be aware of some of the adverse, what I call institutional psychology.

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Sufferers of PTSD as I said before, do experience a sense of detachment. Now this becomes a problem for their families and loved ones because they're wanting to help the person who's suffered the PTSD but the injured worker is actually pulling away and disconnecting. One of the characteristics of the condition is this sense of detachment, sense of emotional disengagement from others. Probably that reflects that this is an anxiety disorder. People when they're very anxious are very focused in on themselves. When they've been multiple traumas they can be having terrible nightmares about the incidents. They can be fearful that they're going to contaminate their family members if they talk about it and I'm sure all of you can easily imagine how hard it must be to be living with someone who's behaving in that way when you know that they're distressed but they won't let you in.

Just remember again what I said earlier on, PTSD is primarily an anxiety disorder but in this condition it's very common that you'll see people manifesting their anxiety in the form of anger. So you'll see irritability, aggressive outbursts and again, this is not only a problem for family members, it can also be a problem for everybody who's trying to help with the rehabilitation. The symptoms have to persist for more than one month and as I mentioned earlier on, unlike acute stress disorder, the condition isn't diagnosed until at least six weeks after the event and unfortunately it very commonly will run a chronic pathway.

There are lots of new, good treatments around for PTSD. Many of you are probably aware of some of the civilian outpatient programs such as those that are run by Dr Andrew Khoo through the Toowong Private Hospital. By the way guys, I don't have shares in Toowong Private Hospital. I'm just mentioning Andrew because he's absolutely excellent and anyone who likes iView the – what's that program on ABC at 8:30 on a Monday Night? Four Corners. Four Corners from last week was on PTSD. So if you've got the time, get onto iView and watch that program. It'll give you a really good sense of the issues around PTSD and the treatment that's now available.

Facilitator:                                

Sorry to interrupt again Josie, but we do have a question. How long can PTSD last and in your opinion can PTSD occur from a minor traffic accident where the PTSD has occurred out of being threatened by another driver?

Dr Josie Sundin:

If you're unlucky, PTSD can last for a lifetime. We know this certainly from the soldiers who came back from World War Two, the soldiers who come back from Vietnam, and it will last longer if you develop comorbid conditions such as secondary major depressive disorder or if you've self-medicated through drugs like alcohol or cannabis, these will aggravate and maintain the PTSD for a very long time.

The question about a relatively minor incident, again, this goes back a little bit to the comment I made earlier. Remember that something that seems minor to you can be major to another individual and it can be very hard to judge how unpleasant was that interaction. So, I'm going to hypothesise here for a moment and imagine a scenario where a worker's been driving to work. They've back-ended another driver or been back-ended by another driver and the driver of the other car gets out and starts screaming at them. Now, most of us would probably find that unpleasant, but would get in the car, go to work, have a really good bitch with our colleagues, get over it and be much happier.

But if you're an individual who's grown up in a bullying atmosphere, a situation of abuse or had multiple traumatic incidents occur to you, either at school, at home or in other workplaces, you will be more vulnerable to developing PTSD in that situation. So, while the diagnosis does require an individual to have a sense – to experience a threat to their actual integrity, I was trying to err a little bit on the side of kindness and take into account the person's back story. Putting on my forensic hat just briefly, if the back story has no past history of other traumas, no past history of any harassment or other arousing type situations, then I'd be more inclined to think about this as an adjustment disorder rather than a Post Traumatic Stress Disorder because I wouldn't be satisfied that it was necessarily sufficiently major event to meet the necessary criteria.

One little final interesting furphy because I'm a queen of trivia, the other group to be aware of is that children of sufferers of PTSD are more vulnerable to developing Post Traumatic Stress Disorder themselves. So some of your younger workers may well indeed be the children of Vietnam veterans who have suffered PTSD for many years. Those workers, if they're involved in a traumatic incident, will be at greater risk of developing PTSD than another member of the population.

Slide 10

Now we've got our first poll question. I'll give you a bit of time to have a look at that.

Rachel, do people get to vote or do we just let them think about it?

Facilitator:                                

They get to vote

Dr Josie Sundin:                      

Fabulous

Facilitator:

And we'll show them the answer.

Dr Josie Sundin:

Excellent. Thanks.

Okay, so can we bring up the answer?

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Okay, so the age bracket when psychological injuries most commonly occur is 36 to 45. I'm hoping everybody – good, well done. Congratulations everyone. Yes, the voting was very good, although there's quite a few non-answers. So feel very free. The joy of this being anonymous is that it doesn't really matter if you get it right or wrong.

We've had a question is "What happens if the person is a loved one and deny they need help?" That's obviously a very difficult situation. I would be trying to use other family members, close family friends or perhaps the family GP to sit down and have a chat with the individual, maybe with the spouse who's there, chatting to the GP, talking about the things that they're observing. That is very difficult. Denial is part of the avoidance that classically occurs in PTSD. People don't like talking about it and that can then make it even more difficult again.

Now, unless we've got any more questions we're going to move on to talking about personality.

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Personality refers to people's enduring qualities. It's the deeply engrained aspect of their personality and personality develops over many years. In the world of psychology and psychiatry we don't consider that someone's fully developed their personality until they're around 30. Personality is observed through behaviours in the way that people relate to the world…

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…and it's important to remember that personality is going to very heavily influence the expression of psychological distress. If a person is suffering from pain, frustration, confusion, feeling lost or abandoned, this can echo back with past experiences. It's also important to remember that the more distressed we are, the more in pain we are, the more chronic a condition has become, the more that pre-existing personality characteristics will be exaggerated. It's important to remember also in this area that for people who are stressed, who are anxious, people who have particular personality vulnerabilities, it can very much be the case that they are having difficulty understanding what's going on.

So, never assume that people have understood you. Stressed people hear and understand less. I often laugh that one of the best reasons that I did medicine in the first instance before I became a psychiatrist is that I liked anatomy and I can still remember most of it. The number of patients I had coming in asking for me to do drawings of their upcoming surgery because they had a nice chat with the surgeon, but they still didn't actually understand what's about to be done, is extremely common. So, it's checking back with people all the time is very important.

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The reason I put this in is that apart that I'm an absolute devotee of the great Leunig cartoons is that you'll often hear flashed around, people talking about personality disorders. But again, emphasising the comment that I made earlier on. Certain personality traits will be exaggerated in situations of stress. So, the dogmatic individual that you encounter within the workplace can become almost frankly OCD if they're stressed enough. The person who is somewhat hyper-vigilant to grievance or sensitive to criticism can become quite frankly paranoid in the setting of a claim and this of course is going to make your life managing them much more difficult.

Slide 15

Resilience is a characteristic that is a behaviourally-adaptive process. This isn't necessarily something that you're born with. It's something that develops over time. It's one of the things that can be – it's built upon by families, by the community within the workplace and it's nice to think about it that way because it means that we can all contribute to improving an individual's resilience. It's all about the interaction between the individual and their environment and resilience is talking about a person's capacity to cope with stress and adversity.

Again, coming back to my earlier comment, people come to the workplace with their pre-existing personalities and life experiences. Many of those life experiences may have made them less resilient and they're going to need more work to be managed in the setting of a claim which itself can become quite stressful. But on the flipside of the coin, the good thing about working to create resilience is that it actually can then make a very positive difference to the work environment. People seeing that a claim is well managed within the work environment within a team atmosphere that creates a positive culture within the workplace and generally makes things much better.

Slide 16

I also like to make the comment around this time that it's not uncommon for me to be asked the question with a prolonged claim, "Is this person malingering?" In my experience the true malingerer is a rare beast. Most people actually want to get back to work and get on. People spend a lot of time at work. Most people define themselves significantly in terms of their work. So the loss of the workplace can be quite a major loss for anybody.

Slide 17

So getting back to the challenging personality types and I'll leave you guys to read this as I go through it, but starting at the top with the paranoid personality type, these are those who hold grudges. They, and when I say "longstanding grudges" a person who's got strong paranoid personality traits can hold grudges quite literally for years. They're prone to being intense, secretive. These are the ones who are going to leap to a civil litigation claim as soon as possible. They're also people who can be quite explosive. They're very self-oriented in terms of perceiving themselves as victims and they will be very sensitive to anything that they think is about their claim being mishandled or denied.

Second group I've talked about is the antisocial or the narcissistic. Again, another group of very self-oriented individuals and remember, narcissism can in fact be quite a healthy personality trait. If you weren't a little bit narcissistic you wouldn't get up in the morning, have a shower and try and dress well, or at least dress neatly for the workplace. You want to present yourself well, you want to look after yourself. Well, narcissism only becomes a problem when there's a reduction or absence of empathy, a failure to reflect upon the way that your behaviour is impacting upon others and a tendency to become impulsive or explosive.

Histrionic – being a female I can talk about gender bias quite happily here. Women are classically labelled as being histrionic. For those of you who love your history, the term histrionic actually comes from a Greek work "histros" which was the word for the womb and in that era it was considered that the reason women were emotional was that their wombs migrated around the abdomen and wherever it sat at the time determined the nature of the emotion. I don't know about any other woman on this chat, but I'm certainly grateful that mine doesn't migrate on a regular basis.

But histrionic characteristics do get ascribed to women. We tend to have greater flair, a tendency to dramatize, but again, these histrionicity is a normal characteristics. It's only when it gets exaggerated that you're seeing demanding, stormy interactions, seductive behaviours that it becomes a problem within the workplace, and to be fair to the gents, guys tends to get overly labelled with the antisocial or narcissistic label where women get overly labelled with the histrionic. So just think about your own personal gender bias.

Now, obsessional personality traits, again, most of the time obsessional workers are highly valued within the workplace. They're rigid, they know the rules, they work hard. They're not particularly warm people, but again if they get stressed or there's an injury or there's some difficulty within the workplace, they can then become quite cold. They can be very controlling and they can be quite difficult people to work with. Within this group I'm often fascinated how much preoccupation with perceived rules about justice can become an issue. This group find it very difficult to shift on and to accept that the world doesn't actually necessarily turn according to how they believe it should, capital S H O U L D, go round.

And finally Passive-aggressive. Personally I find this group the hardest bunch of all. Because of the absence of overt acts, they're resistant, they're stubborn, they're sulky, they're inclined to blame others and rarely do they actively participate in resolving their own problems.

Yep, Rachel. We've got a question?

Facilitator:

Hi Josie, I do. It's specifically looking at the topic of challenging personalities and where there is a diagnosis, quite a vague diagnosis of workplace stress, whether that is by psychiatrist or mostly you'd see that with the GP, what can an employer do to I guess, encourage a worker who's not wanting to engage in return to work discussions to come onto that journey with them?

Dr Josie Sundin:

I think that the very first step is all about listening. Often where you're getting someone who's reluctant to return, the problem may very well be that they up to that point haven't really felt heard. So if you can take the time to sit and listen to them, and let them go through their grievance, their anxieties at some length that will take them a long step further forward to be confident that their return to work will be well managed.

Slide 18

The other thing is that people who are reluctant or avoidant about returning to work are usually people who are anxious that they're not going to be supported or that the problems that were in the workplace before will be repeated and they'll be abandoned and left to manage on their own. So, work that can be done to arrange a meeting with the HR staff, the Supervisor, the Manager before any return to work actually occurs, can be extremely beneficial. It also helps a lot if you can arrange to have a meeting with the worker and their general practitioner or psychologist in the lead-up to a return to work plan so that all of the concerns are aired.

Speaking for psychiatrists and psychologists, general practitioners, we can all make the mistake of falling into the role of advocate and seeing the employer as the big bad nasty and not really stopping to think about what the bigger picture is and what the obligations are on the worker and the employer as regards any kind of return to work program. So reminding GPs that there is an item number for case conferencing so that you can come in and have a chat with them, with the worker present about the plans, can go a very long way.

Obviously, there's always going to be the difficulty if you've got someone who basically has set up a set of unmanageable rules. I have a worker I'm trying to sort through at the moment who essentially wants the employer to sack her immediate Manager and anything less than the sacking of her immediate Manager isn't going to satisfy her. She's a woman who works in a somewhat remote area so there are limited alternative employment opportunities and you can find at those times struggling to work through what's the actual accepted claim and what is the secondary grievance about the process, and as I understand it and I'm happy to be corrected here, a secondary grievance about the process isn't compensable. And sometimes in those situations you may end up needing simply to close the case by sending the matter to an IME and having the case then referred for a psychiatric tribunal for conclusion. I personally don't think that's ideal but we have to work with the real world here and the intransigent worker talking back about those personality types from before such as the obsessional or the passive-aggressive can indeed be extremely difficult to manage in that situation.

Slide 19

Okay, so we're up to our second poll question asking you "What's the average length of time off for an injured worker with a psychological condition?" So I'll give you some time to have a bit of a think about that, and please, everybody have a go at voting.

Slide 20

The answer is 150 days lost. Do we have the voting information, because I think the common perception is that it's a very long period of time. Mind you, 150 days is five months, so it's quite a length, isn't it? Okay. Just waiting to see. The poll's ended. Do we have the votes in? Okay, all right. Most people thought that it was – of those who voted that it was 100 days lost and then we've got a fairly equal split between 150 and 200 with just a few outlies at either end.

Slide 21

Okay, now coming to talking more about the challenges and I've mentioned some of this before, expectations are an important thing. Mismanaged expectations lead to poorer outcomes and as I've clearly gone on during this talk, it's incredibly important to understand and manage your prejudices, theirs and others. If you aren't aware of your own particular prejudices then you're going to have more – have greater difficulty in managing a claim. For example, we were talking earlier about the issue about a minor versus a major incident. You can find yourself thinking "Well, this worker is having a bit of a lend." Try and maintain a neutral stance. Try and keep that attitude on hold because otherwise you'll end up being antagonistic and that's only going to aggravate the claim.

Equally you can have the worker's prejudice that you as a Claim Manager or a Return to Work Coordinator can be seen – identified as the enemy and the lackey of the employer and not there to help them, and again, if you can just gently sometimes raise expectations and try and be quite clear about these, preferably as early as possible, you're going to get a better outcome. The more that people can understand what to expect, both of the outcome and the process, then the better they're going to do, and as I mentioned earlier on, keep on checking in with the worker to understand that they're understanding what you're saying to them and how the process is going to proceed.

We've got another question.

Facilitator:

Hi Josie. We've had a few questions that relate to I guess, trying to contact a worker when they simply refuse to provide any permission to contact their doctor or they won't speak with you. Can you just tie together how some of the symptoms might manifest into that kind of behaviour and do you just keep trying repeatedly to contact them, either in writing or other?

Dr Josie Sundin:

I love doing webinars with experienced people. You ask such easy questions. Okay, how much is enough? That's obviously an extremely difficult situation. As I understand it and I'm happy to be corrected by others present, if you're on a WorkCover claim then you actually have an obligation to participate in your own rehabilitation process and that means that your doctor or your psychologist has to also be involved in the claim. I don't know that you actually have a right to refuse, that the worker has a right to refuse that nobody else will be involved and that all other information is withheld.

I think if you can identify someone such as the psychologist or the GP, preferably perhaps by email or sometimes if it gets to be – you might need to do something like send out registered post just giving them a quick précis of what's going on and what your goals are, then you might be able to engage that person to participate in the program with you and in moving things forward.

Slide 22

Now, I'm just going to flick forward to one of my own personal favourite cartoons of all time. I'll just be quiet while you guys have a little bit of a read.

For anyone who ever doubted that Leunig was a genius, this is my opinion, this cartoon proves the utter genius of the man and I put this cartoon in simply because you undoubtedly at times find yourself dealing with unrealistic expectations from workers. A life free of pain is not possible for anyone. A life full of positive affirmation is never going to happen for anyone. We all have to develop some resilience to be helped into moving forward and accepting that life is going to throw up difficulties for us from time to time.

Now, you're all probably thinking to yourself "This is a fairly self-evident concept, but in the pain area I think this is one of the most difficult things that workers understand and I think their expectations are badly handled because of all the wonderful doctor shows on telly and the movie where people get rapidly better in the space of an hour and all is well. If you have an expectation that an injury is going to completely recover and you'll get back entirely to your premorbid status, then if you think it through clearly that's going to be a less good outcome.

So again, if workers in those sorts of situations will allow you to talk with them, with their doctors, then it's going to help you to manage their outcome. Doctors don't like delivering bad news any more than anybody else does. So sometimes you might need to be the person that prompts the question, "How much recovery can Mr Jones expect?", "How much pain is Mr Jones or Mrs Jones likely to expect to suffer from here?" The injuries where they're reported by the orthopaedic surgeons to be an aggravation of a pre-existing degenerative change, often the hardest of all to manage in this situation because the worker will quite rightly say, "Well, I wasn't in pain before this. I yanked on the tyre iron and I haven't been able to walk since," and it's not your job to explain to them the difference between an acute injury and pre-existing chronic degenerative change. In my opinion, that's the job of their doctor and I think if there's any situation where you can have a chance to sit with a worker, with their doctor or with their physio and help them to understand the physiology of what's going on and to get a bit of an understanding as to how emotion will aggravate pain and pain will aggravate emotion, then again the better outcome a worker's going to have.

I think at some stage it's planned actually to do a program through the webinars to talk about pain and the management of pain because in my experience that's often one of the most difficult things for people to encounter and try to explain to others.

Slide 23

Now, rehabilitation and return to work plans obviously are very important. I think I've talked about this in a reference manner as we've been going on today, but it is important to think about when you're making these rehabilitation return to work plans, to understand them in the wider context. Older workers are going to be harder to return to work. Older workers are going to struggle if they have to go to a host because as everybody knows, the economy isn't as strong as it used to be, so redeployment can indeed be quite difficult.

People can have an expectation that a WorkCover claim will go on forever, so again, it's important to manage their expectations to help them to understand that there is a limit to how long a claim will be run, and again, although it's not compensable, the more that you understand the background to what's going on in the worker's life and the way in fact their time off work or their injury is affecting others around them, then the better you're going to manage them. If I said just one word over and over and over it would be "listen," "listen," "listen." The more that you listen, the more that you'll engage with the worker, the better they will feel about the process, the more responded to they will feel and the better outcome that you're going to get.

Slide 24

Okay, return to work obviously has some really quite significant benefits and there's a number of people who are going to be involved. It may be that a worker needs to be placed on medication and that may be provided to them either by their general practitioner or by their psychiatrist. They're also going to need some assistance in terms of counselling. This may be done by a psychiatrist or a psychologist and a lot of the counselling is going to be based in the area of cognitive behavioural therapy, helping people to understand and identify the dysfunctional thoughts that might be getting in the way of the psychological recovery and developing a functional set of cognitions and behavioural solutions that will help them to move forward.

One of the things I haven't listed it there, but can also be incredibly helpful in managing adjustment disorders when they're secondary psychological claims after a physical injury is getting people to be involved in some sort of physical rehabilitation program. I know that a lot of you send workers along to gymnasiums or to personal trainers. This is a very valuable manoeuvre. It helps people to feel stronger and safer in themselves. That promotes a sense of resilience, a sense of personal competency and confidence and you'll see a reduction in the psychological symptoms as a consequence.

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Again, I'm clearly the queen of cartoons. I do collect these and so if any of you've got any good ones around the area of return to work or rehabilitation, please forward them on because I'd like to collect them. The reason I've incorporated this is just simply it makes a lot of sense, doesn't it? I'm a doctor. I'm a psychiatrist. If I get sick I've got a really good idea of who are going to be the best people to work on me. I actually have a personal advantage. One of my very dear friends is the nurse in charge of the operating theatres at the Wesley Hospital, so if I ever want to check a surgeon then she's the person that I phone up. Equally though, these days on the flipside of the coin, there's an awful lot of quite fascinating and sometimes I think quite libelist comments made about particular doctors on Rate my Doctor or Rate my Psychologist, and you need to take that into account in terms of how workers are responding and how they're assessing what's going on.

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So we're now up to our third poll question which is "What do you think is the percentage of return to work after a psychological injury?" Again, I'll give you a little bit of time just to answer this.

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All right, the poll has ended and the correct answer is – should be popping up. There we go, yes, 75 to 90 percent. Now that's a really good outcome and hopefully everyone feels quite happy to have a sense that we do get good results and in fact most of you thought it was much lower than that. So, I hope we reassured you.

Now we've got two questions that have been sent in. "How do we manage a suitable duties plan for a psychological injury?" Again, it's mostly about working with the psychologist, psychiatrist or general practitioner to develop a suitable duties plan that revolves around a graduated return to work. Planning before the worker ever returns to work is particularly important. Thinking about taking it up gently, for example starting maybe at four hours a day two or three days a week and gradually increasing from there so that you're in effect, desensitising the worker and increasing their confidence.

If you can do things like meet the worker at the workplace perhaps the week before the return to work and maybe have a coffee with them at a nearby coffee shop, just to answer any last minute questions they have, meet the worker on their very first day of a return to work so that you can go with them into the workplace, they know that you know where they are, they've got your number or your email to contact if there's any anxieties and then checking in with them fairly regularly over the first two to three weeks to make sure that all is going well.

Again, communication is the key. The more that you're talking to people, checking on how they're going as that graduated return to work occurs, then the better it's going to happen. Also the more that you're encouraging them to contact you if they're having any difficulties, then again you're going to pre-empt and solve problems before they get bad.

We have another question which says "What precautions should an employer take when building a suitable duties plan for a worker that works alone or a worker who works remote from other people?" I'm not entirely sure because I haven't really encountered that. These days it's pretty uncommon for people to work entirely alone I would have thought, but clearly that does happen. Maybe the employer needs to be making sure that they've pre-agreed with the worker that there's going to be phone or text contact on a daily basis when the worker first gets back, that the worker is aware of lines of communication, who to contact if they're having any difficulties and I suppose the other thing you as return to work managers could be thinking about is just checking with that worker to make sure that they have got some work/life balance going on so that they're not slipping into a very isolated existence. The other thing of course is that there will be support available from the provider within their local area and that may help as well. I'm sorry if that's not the world's most satisfactory answer, but it's not a matter I've had much experience with.

Slide 28

Now as regards to the rehabilitation and the return to work tricks, tips, remember pre-existing conditions can be retriggered by new injuries. Now that doesn't exclude a worker from having a new workers' compensation claim. So, for an example you may have a worker who's suffered post-natal depressive disorder in the past or a major depressive disorder in the past who suffers a physical injury or harassment in the workplace and that person is more vulnerable to developing a recurrence of their major depressive disorder. If that recurrence is mismanaged then you can find yourself there with a further claim.

The better that you manage the worker's anger the better the claim will progress, remembering again my comment from earlier on, anger and anxiety, flipsides of the same coin, all driven by adrenaline. If you can formulate the angry worker as an anxious worker it makes it easier for you to be empathic and to sympathise and to assist them with their return to work.

As I said earlier on, try to resist assuming that malingering is occurring when a claim goes longer than expected. As you saw earlier on, we do have a really good return to work, 84 percent, but that tells you on the flipside that 16 percent don't return to work. These are the people who have the chronic conditions, who may have multiple other factors going on that prevent the return to work and these individuals ultimately prognositically do a lot less well. They come before me in our tribunals and can really struggle. When I've got a patient like this I'm often doing a lot of work trying to get them to develop other aspects of their life such as volunteering or recreational activities, understanding that leaving work is a big adaptation in itself and that can then be associated with a lot of psychological morbidity in the aftermath.

As I said, try and contextualise the stressors to better understand the worker's perspective. If we use that great example that someone suggested earlier on, if you're in a car accident and if you happen to be a petite little 50 kilo female and some big burly six-foot-four tattooed wonder is standing over you screaming at you because you've back-ended his fantastic ute, then that's going to be a far more unpleasant interaction than if I happen to back-end another middle-aged lady and we both spend our time apologising to one another. So remember the context. Context is king.

Finally as regards the return to work tips, one of the biggest criticisms that can be made of doctors in trying for you guys is that we as doctors tend to see ourselves as our patients' advocates. Not a lot of doctors work in the workers compensation areas. So they don't understand the rehabilitation legislation. They don't understand the rehabilitation philosophy. They don't understand that we actually have good outcomes in return to work and that a return to work is actually associated with a better long-term psychologically. It can be very easy for doctors to misunderstand and to perceive the return to work as actually making life more difficult for the worker.

So again, trying to educate the doctors and we obviously need to do that better at our end as well to make your lives more easy, but this is where just to mention, Workers' Compensation Central has a great program where they've got three psychiatrists who are there to help in difficult claims, that Dr John Chalk, Dr Jenny Gunn and Dr Quentin Mongomery, all of whom are available for you to phone up and talk about your difficult cases.

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So use them. They're happy to be used.

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They've got great resources.

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They're employed to assist with difficult claims and they may indeed be the person that at some point you need to say "Look, can you ring this bloke's GP for me because we're just not getting anywhere?" and I'm sure that is something that they'd be keen to help with.

Now, where are we at? I think we're there. No, just last but by no means least. We've added on some resources for all of you. Again, these are in the slides that are going to be sent out to you. These are fantastic websites for workers.

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People have been asking about the house-bound worker or the avoidant worker. Sometimes it might very well be that one of the things you ask them to do is start looking at the Beyondblue website or the Black Dog Institute website at home. These websites have got lots of explanations about psychiatric and psychological conditions, but even more importantly they've got fantastic things called "Mood Gym" and strategies that workers can use to try and build their own resilience to help them to feel stronger. Nietzsche who said "Knowledge is Power" was absolutely right. The more that the worker understands what's going on with them, the more confident and in control they'll feel, and the better outcome they'll have.

So, keep all of these resources and feel very free to encourage your workers to have a look at these whenever you're dealing with psychological claims.

So thank you very much for your attention and your participation. I apologise if I've rambled and if some of my answers were a little bit less than satisfactory, I have to simply say you are clearly a clever bunch and you've asked some quite difficult questions. So, if I ever do this again maybe I could get the easy questions please.

Thanks everyone. Bye.

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Facilitator:

Okay. Well that concludes our webinar for today. I'd just like to extend a very warm thank you to you again Josie. It's always a pleasure to hear you speak and it's a pleasure to be facilitating I guess, between your presentation and some of the questions, and we had a lot of questions today. So it's a topic that we know interests people and they definitely need some more help with.

Okay, as Josie outlined there are many resources that are available to you and the Workers' Compensation regulator is committed to supporting you in your roles. We've established a Return to Work Coordinator Community and we encourage you to join that. Later this year, so we've got one next month actually, we've actually got our conference in Townsville.

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So we're also committed to delivering education initiatives across the whole of regional Queensland as well as South-east Queensland. This year's theme is “leadership and influence" at our Townsville conference on the 24th of April. It's a Friday.

We hope to bring you a mix of world-class speakers on a range of topics and some really practical ideas for you to take back to your workplaces. If you come, you'll be able to meet Josie in person and learn best practice management of those complex psychological claims including secondary psych injuries.

So finally on behalf of the Workers' Compensation Regulator, thank you for joining us today and being involved in our new imitative for Return to Work Coordinators. Have a good afternoon.

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