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Breaking Breaking the Web of the Web of “Needless “Needless
Disability”:Disability”:
Reducing the Impact of Secondary Psychological Claims
Robert AurbachPrincipal ConsultantUncommon Approach
Some people recover as Some people recover as expected…some spiral expected…some spiral down into despair and down into despair and dependencydependencyHow can you impact the worker’s outcome?
What are “secondary psych” What are “secondary psych” claims?claims?
Some claimants develop psychological “signs and symptoms” in addition to their original condition◦Symptoms are what the worker reports◦ “Signs” are the objective observations of a
trained medical professional and include the results of objective testing
◦The comparison of “signs” and “symptoms” for consistency is an important part of claims management
The secondary condition can be a more serious blocker to return to work than the primary injury.
““Secondary Psych” claims are Secondary Psych” claims are importantimportant
We are addressing the reason that some people get better and some people do not
Corporate perspective:Corporate perspective:
Secondary Psych is a major cost driver underlying most failure to return to work and extended incapacity payments
Personal PerspectivePersonal Perspective::The cases where there is an unnecessary failure to recover/resume normal life make up the majority of the 20% of claims that cost about 80% of our time and resources
It’s helpful to understand It’s helpful to understand Secondary Psych better…Secondary Psych better…
Without a model of what’s happening, all you have is studies that show correlations between various factors and disability.
But a model of how this happens helps us to intervene effectively
We’ve learned a lot about how the brain We’ve learned a lot about how the brain works in the last few years….works in the last few years….
• We learn almost every complex behaviour in the same way
• It’s been proven with experiments directly on the brain
• And proven by “miraculous” cures– Stroke and head injuries– Recovery from “phantom” pain
The brain has to make sense of a The brain has to make sense of a LOTLOT
Everything that is coming in at one time is processed together
The links between thoughts, emotions, and sensations are links in TIME, not in causation
First Law of NeuroplasticityFirst Law of Neuroplasticity
Neurons (brain cells) that fire together, wire together” This is the first law of neuroplasticity (don’t worry… there are only two)
The brain cells that are linked together are called a “neural network”
Neural NetworksNeural Networks
Have you ever experienced a song, a scent, or a picture that brought up memories of another time or place?
There is a change in the There is a change in the neural connections with neural connections with repetitionrepetition
Nerves fire faster and more automatically
Less “conscious thought” is involvedThere is less opportunity for
examination of the reaction
Why “facilitated neural networks” Why “facilitated neural networks” are critically importantare critically important
When things are associated in facilitated neural networks, the stimulation of one part of the network fires all the things that are linked into it thoughts emotions physical sensations (including chronic
pain)
We learn almost everything this wayWe learn almost everything this way• How to speak without thinking about how to
form the words• Playing music or sports• Habits• Superstitions• How to take the role of a “victim” or a
“disabled person”
“Practice Makes Perfect”
How do we Learn?
How much repetition is “enough”?How much repetition is “enough”?• Changes in the brain begin to happen very quickly,
and more quickly when attention is focused• “Mental rehearsing” is nearly as effective as physical
experience in creating and solidifying the neural network*
• This is the operational mechanism behind the research on the impact of delay of return to work (probability of return <50% after 12 weeks lost time)
The mental rehearsing turns out to be The mental rehearsing turns out to be the “most important” for the “most important” for understanding disabilityunderstanding disability
That’s where the opportunity to affect the outcome is most often present
Sometimes we call this mental rehearsal “self-talk”
LOSS OF CONTROL
PAIN (fear of pain)
ANXIETY
Anger, frustration, worry, catastrophic thinking
Environmental messages
Economic Pressure Specificnegative messages
Loss of (work) Identity
Sleeplessness(fear of sleeplessness)
Psychosocial factors
The “Web of Disability”
Copyright 2012, Robert M. Aurbach
The “Simple” formula for DisabilityThe “Simple” formula for Disability
Negative self-talk > ability to “overcome” the negative messages = loss of control
What does it feel like to be out of control?Loss of control is an intolerable state,
which requires a person to adopt a new “identity” that is consistent with “regaining control” under the circumstances
Our cultural environment often suggests the role of “Disabled Person” to the injured
If a new identity as a If a new identity as a disabled person is disabled person is
resisted, then the strain resisted, then the strain of living out of control of living out of control
can be too muchcan be too much
That’s where we see the development of
secondary psychological injury
There are two ways to prevent There are two ways to prevent adoption of the “Disabled” Mentality adoption of the “Disabled” Mentality
or Secondary Psychological Injuryor Secondary Psychological Injury
Reduce the negative inputs (Interventions that influence how the system impacts the worker)
Change the nature of the self-talk (Interventions that look to bolstering the workers’ “resilience”)
EffectivelyEffectively reducing the negative inputsreducing the negative inputs
You CAN have an impact
Fix things Fix things before they get bad – before they get bad –
Early Intervention
““Fixing things” should be done Fixing things” should be done quicklyquickly
Creation of a “Web of Disability” takes repetition
Repetition takes timeIf the thought, emotion or sensation
is removed quickly enough, the new “habit of thought” including it doesn’t have time to become entrenched
Why Early Intervention WorksWhy Early Intervention Works
Reduces loss of work identityReduces opportunity for specific
negative messagesReduces anger, frustration and
catastrophic thinkingReduces anxiety and sleeplessness
The “Second Law” of NeuroplasticityThe “Second Law” of Neuroplasticity• The brain is wonderfully efficient and will
“recycle” resources that aren’t being used• “Use it or lose it” Put someone back to work, and the habits
around staying home get replaced with work routines and thought patterns
Why Return to Work is effectiveWhy Return to Work is effective
Reduces loss of work identity
Reduces economic pressure
Reduces anxiety and sleeplessness
LOSS OF CONTROL
PAIN (fear of pain)
ANXIETY
Anger, frustration, worry, catastrophic thinking
Environmental messages
Economic Pressure Specificnegative messages
Loss of (work) Identity
Sleeplessness(fear of sleeplessness)
Psychosocial factors
Combination of Early Intervention
& RTW
Copyright 2012, Robert M. Aurbach
Inadvertent actions in managing Inadvertent actions in managing the claim canthe claim can
create create needless disabilityneedless disability
NONE of this is an issue of “fault” but most can be reduced or prevented◦Delay◦Implied messages◦Driving the claimant into the hands of lawyers◦Failure to set positive expectations◦Failure to acknowledge and respond to what
they are experiencing
What can you do?What can you do?
Be responsive and acknowledgeRealise that no matter how many pending
files you have, his or her case is the only one that is important to them
Understand that your actions have a massive impact on his or her retention or loss of the critical sense of control over his or her own life.
There’s a third line of There’s a third line of defencedefence
Changing the nature of the self-talk
Resilience
Research on ResilienceResearch on ResilienceData shows that people with high levels of
resilience were:◦Less likely to have time off following injury
◦More likely to recover and return to work quickly
◦More emotionally and physically ready to return to work
◦Less likely to believe that someone else was responsible for their injury/accident
What is “resilience”?What is “resilience”? The literature has “defined” resilience by its
observed effects We “foster” resilience by things like encouraging
people to “increase their self esteem” and “promote good relationships“ and “be hopeful”
This circular approach hasn’t proven very effective
What we call “Resilience” is really the ability to resist negative self-talk
How does it work?How does it work?
Repetition is necessary to make the changes in the brain that are associated with disability
The repetition comes mostly from self-talkIf we can build up the ability to quiet the
self-talk, the sense of loss of control doesn’t get stimulated as much by the claims environment
If the negative self-talk is If the negative self-talk is quieted, then it’s easier quieted, then it’s easier
to keep a sense of controlto keep a sense of control
If people keep their sense of control, they can “bounce
back” better from adversity
There appear to be four strategies There appear to be four strategies used (singly or in combination) by used (singly or in combination) by resilient people in resisting negative resilient people in resisting negative self-talkself-talk
Drown out the negative messages (“Believer”) Change the negative messages (“Reframer”) Make the mind too busy to attend to negativity
(“Achiever”) Create separation of the sense of self from the
source of the negativity (“Distancer”)
We can tailor the We can tailor the intervention to the intervention to the
existing “resilience” styleexisting “resilience” style
By working with the injured worker’s strengths, interventions
can empower -instead of creating dependency
A “better” simple A “better” simple formula:formula:
Early Intervention/Return to work + Maximizing inherent resilience = Substantially fewer instances of unexpected failure to recover
