Transcript Psychotherapy with Work Injured Patients Owen J. Bargreen

Psychotherapy and Evaluation with
Work- Injured Patients
Owen J. Bargreen, Psy.D.
Clinical Psychologist
Trinity Lutheran College
[email protected]
WWW.BARGREENPSYCHOLOGY.COM
Overview of Presentation
- Referral process
- Evaluation
- Research of techniques/therapeutic orientations
- Opinion on techniques/therapeutic orientations
- Treatment of work injured patients
- Common problems and symptoms
- Special Topics
- Labor and Industries/ Insurance carriers
- Case studies
Process for Patient
 Person suffers work injury, may be
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psychologically based injury
Patient placed on time-loss, light duty or full
time duty
Issues with being placed on time-loss
Mental health issues ensue after accident
Need to prove causality
Patient’s behavior noticed by doctor or
lawyer; sometimes spouse or friend
Patient is then sent for diagnostic evaluation
Referral Process
 Referral sources (doctors, lawyers, etc.)
 Symptoms noticed by referral source
(depression, anxiety, anger, insomnia etc.)
 Primary care makes the call
 Problems with referral process (referral
does not mean treatment/evaluation)
 Independent Medical Exam (IME) results
can approve or deny evaluation/treatment
Referral Process Cont.
 Cognitive testing/ neuropsychological
testing/ malingering
 Referral in writing to claims manager for
psychological evaluation
 Psychologist completes psychological
evaluation
 Patient either approved/not approved for
therapy; authorization process
Evaluation of Work-Injured
Patients
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Cognitive testing
Neuropsychological testing
Personality testing (rarely approved)
Diagnostic evaluation (depression,
anxiety, insomnia, etc.)
 Evaluation might assist vocational
 Report sent to referral source and/or
claims manager
Cognitive Testing
 Client has a history of learning issues
 Client has history of concussions/head
trauma; check for malingering
 Client has learning issues that serves as
barrier from them from working
 Client is given battery of cognitive tests, data
analyzed, report written to L and I; copy sent
to referral source
 Vocationally based evaluation
Neuropsychological Testing
 Client suffered a head injury
 Client has a history of head traumas
 Especially those who have lost consciousness due to
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a head injury; malingering
Client self-reports memory problems
Client self-reports learning or
attention/concentration problems
Personality disturbance due to a head trauma
Client is given battery of cognitive/ memory tests,
data analyzed, report written to L and I; copy sent to
referral source
Vocationally based evaluation
Personality Testing
 Personality constructs interfering with
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return to work; preexisting conditions
Usually assessing Axis II, thought disorders
(Rorschach, MMPI-2 or Millon-2)
MMPI-2 (Scales 1,2, 7 commonly elevated)
Rarely approved; other providers use more
Can have vocational significance
Diagnostic Evaluation
 Sample evaluation: Psychosocial history, work
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injury, previous mental health problems,
current mental health problems
Labor and Industries standards, behavior
rating, 5 Axes, etc.
Initial eval /60 or 120 day diagnostic
evaluations
Treatment plan, barriers for return to work
Evaluation of personality and mental health
issues; then sent to L and I and/or referral
source
Research on Psychotherapy with
Work-Injured Patients
 Roughly 6 in 200 workers
suffer major work injury
(Occupational Health and
Safety Administration,
2000); World Health
Organization (WHO)
indicates 160 million per
year; stats improving
 Gaffney (1997) no research
on psych effects of work
injury until late 1980s. Psych
intervention was “at the end
when medical interventions
failed.”
 Gaffney (1997) Psychological
factors led to a “delayed
recovery” which are due to
factors such as depression
and anxiety, early life abuse,
compromised motivation,
and personality disorders.”
 Cotton (2008) : “Evidence-
based psych interventions
can play in injury prevention
and improved health and
return to work outcomes.”
Proponent of
behavioral/CBT.
Research cont.
 Cotton (2008)
Humanistic techniques
lead to “work avoidance
behaviors become
reinforced.”
 Cockburn (1997) –
efficacy of solutionfocused brief therapy
(SFBT, 6-12 session) and
seen as “very effective. . .
for return to work.”
 Recovery often difficult;
relapse prevention
 Bigos et. al., (1991),
Dworkin et. al., (1985),
Fordyce (1995), Gallager
et. al., (1989, 1995) &
Sanders (1995) “job
dissatisfaction and
occupational stress tends
to have an adverse effect
on the overall
psychological response
and recovery following
accidents.”
 Patient wait time often 6
months- 3 years
Humanistic Techniques
 Unconditional positive regard
 Active listening/mirroring
 Feedback vs. no feedback
Cognitive-Behavioral Therapy
(CBT) Techniques
 Automatic thoughts
 Analyzing thoughts/ cognitive
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distortions/ changing distortions
Thoughts and behaviors helpful for
patient?
Mood monitoring
Journaling/ journal review
Also behavioral model
Psychodynamic Techniques
 Id, ego, superego
conceptualization
 Family of origin issues
 Use of defense mechanisms
 Ego strength for pos. and neg.
feedback
Gestalt Techniques
 Paradoxical intention/ role playing
 Empty chair
 Need rapport
Misc.Theories:Assertiveness
Training/Social Learning
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Passive/aggressive/assertive
Analyzing family/interpersonal content
Making changes using assertiveness
Social learning theory:
Psychoeducation/serving as a
positive/appropriate model
 Also group therapy
Opinion on Techniques
 Eclectic orientation
 Humanistic first
 Then CBT, Gestalt, etc. CBT favored
 Occasionally Existential issues
 Relaxation techniques/mindfulness
techniques/ guided relaxations
 Mind/body connection
 Learn from them
Typologies of Work-Injured
Patients
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Blue collar workers
Language
Rapport
Directive vs. Non-directive
Typologies cont.
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White collar workers
Language
Rapport
Directive vs. Non-directive
Older Patients vs. Younger
Patients
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Rapport issues
Directive vs. Non-directive
Narrative therapies
Educating you
Number One Work-Injured
Patient Typology
 Depression, anxiety, anger, somatic pain
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and insomnia concerns
MDD more rare, usually Dysthymia or
NOS; rarely Bipolar I or II
Sometimes panic disorder, PTSD more
rare
Anger issues usually Axis II features, rather
than PD
Insomnia and pain affect everything
Common Problems and Symptoms
 Examine hierarchy of problems/discuss
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with patient
High prevalence of comorbidity
Marital/ relationship issues
Depression: Major Depressive Disorder ,
dysthymia, NOS
Anxiety: Panic disorder, PTSD, social
phobia
Pain problems; coping with pain
Sleep problems; sleep hygiene
Problems cont.
 Other somatic problems (e.g. sexual
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problems)
Feelings of powerlessness
Pharmacologic concerns/medication
management/ medication misuse/ drugs
and alcohol
Diet and exercise concerns
Preexisting conditions
Axis II problems and anger problems
Impulsivity problems
Problems cont.
 Other problems (housing, time/loss
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financial, social support, etc.)
Learning issues; TBI patients
Negativistic view of doctors/ L and I
Resurrect interests and strengths
Return to work process or SSDI
Scheduling problems
Approval problems
Working with employers
Interpreter Issues
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Job of interpreters
Interpreters late, causes anxiety
Important to build good relationships
Incredible people, diverse backgrounds
Sometimes can make/break treatment
Occasional bad behavior
Special Topics
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Cultural issues/acculturation
Gay, Lesbian, Bisexual and Transgender
Persons with disabilities
Religion/spirituality
Testing with work-injured patients (MMPI-2):
Carefully examine Scale 1, Scale 2.
Negativistic pattern (Eimer & Freeman, 1998;
Greene, 1991).
 Rating progress after therapy
 Termination
Process of Psychotherapy
 Change usually takes months
 Review informed consent/ protection of
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confidentiality
Preexisting conditions (e.g. Axis II)
Behavioral ratings on problems
Entitlement issues/ straight talk about
insurance
Suicide assessment
Problems with Labor and
Industries
 Billing problems/progress notes
 Claims manager problems:
entitlement, lack of education, Axis II
 Department communication
problems (letters sometimes
necessary)
 Blame the system problems/
displacement
Problems L and I cont.
 Case file reviews by L and I doctors/ nurse
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case managers
Maximum medical improvement (MMI)
Causality of symptoms
Pre-existing conditions
Treatment denials for no reason
L and I targeting patients at random
Payment problems (takes months, denials,
coding issues)
Need biller to take nonpayment seriously
Problems L and I cont.
 Testing difficult to get paid; hours problems
 Letters difficult to get paid/ phone calls
unpaid
 Phone call wait times/ just send letters
 Less medical doctors accepting L and I/ need
good provider list
 Secondary Insurance Issues
Working with Biller
 Payment problems (takes months, denials,
coding issues); managing AR with them
 Need biller to take nonpayment seriously
 Needs excellent records; Excel sheets
 Need competent biller with L and I
experience; knows billing codes; claims
manager experience
 Communication with biller essential;
meetings with biller
Working with Claims Managers
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Approval process
Axis II, what to do????
Favorites and enemies
Supervisors and claim leads
Sending letters, not calling
Problems with reaching claims managers
Working with Vocational
Counselors
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Personality spectrum
Can help you get treatment approved
Problems/ incompetence
Vocational portions of your evaluations
Problems with completing vocational
forms
Working with L and I Lawyers
 Many specialize in L and I work
 Many different types of L and I lawyers,
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good and bad; can be a
strength/weaknesses for case
Strong presence of paralegals
Usually connected around time-loss/ back
pay
Depositions; need frank discussions
Independent evaluations for case
Working with Doctors
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Occupational medicine
Sports medicine specialists
Orthopedic surgeons
Psychiatrists
Chiropractors
Occasional consultations
Most appreciate your work; value patient
improvement
 Few see value in testing
 Varied Personalities
Case Studies: P (Cau. Male)
 Middle aged/ Caucasian, blue collar
 Preexisting conditions, Borderline
features, Antisocial tendencies
 Style of therapy, non-directive, generally
open to feedback/ some psychoeducation
 Family problems, emotion regulation
problems
 Assertiveness training
P. cont.
 CBT therapy for depression and
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anxiety; suicide assessment
Systematic desensitization for anxiety
Medication management/pain
management
Rapport essential
Boundaries/ food
M. (Caucasian Female)
 Young, Caucasian female, white collar
 Preexisting conditions, Borderline
features, interpersonal problems
 Style of therapy, more directive,
encourages feedback/ encourages
psychoeducation
 Family problems, emotion regulation
problems
M. cont.
 Communication problems (spouse
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issues), assertiveness training
CBT for depression/anxiety
Medication management/pain
management/medication
misuse/drugs and alcohol
Rapport essential
Boundaries/ date for friend
R. (Caucasian Male)
 Older, Caucasian male, blue collar
 Difficult rapport/Axis II/transference/
countertransference
 Preexisting conditions, Avoidant features,
Schizoid features, Borderline features
 Style of therapy, directive and non-directive,
sometimes open to feedback/some
psychoeducation
 Family problems, divorce, emotion regulation
problems
R. cont.
 Major communication problems
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(assertiveness training, very traditional, less
malleable)
CBT for depression/anxiety, suicidality
concerns
Lower defenses (projection, displacement,
reaction formation)
Medication management/pain management/
drugs and alcohol
Rapport essential
M. (Hispanic Male)
 Blue collar worker/ learning issues
 Acculturation issues/ interpreter
 Preexisting conditions, depression, anger,
avoidant tendencies, education level
 Style of therapy, directive, generally open to
feedback/ constant psychoeducation
 Family problems, emotion regulation problems
 Assertiveness training; empathy training
 CBT for depression/anxiety; suicide assessment
M. cont.
 Medication management/pain
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management
Physical problems contributing to mental
health issues
Financial stress/ masculinity issues
Topics of interest
Working on strengths
A. (Middle Eastern Male)
 Acculturation issues
 Interpreter issues
 Blue collar work/ supervisor issues
 Attack incident/ trauma symptoms
 Systematic desensitization for social anxiety
 CBT for depression
 Medication management with psychiatrist
D. (cont.)
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Directive approach but also learn from him
Masculinity issues
IME problems
Work problems cause trauma symptoms
Cognitive work also improved trauma
symptoms
M. (Caucasian female)
 Blue collar work, issues of male-dominated
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profession
Supervisor and safety concerns
Physical issues prominent, lifestyle change
CBT for depression and anxiety
Anxiety over L and I approval
Secondary insurance issues, letter to
secondary insurance company
M (Caucasian female cont.)
 CBT for thought distortions
 Strong IQ helps learning CBT quickly and
effectively
 Mastered changing thoughts
 Analyzing risk at work; light duty issues
 Might need to find another job
H. (African-American male)
 Combined white and blue collar work
 L and I issues, waiting for treatment
 Distrust issues
 Family problems, some pre-existing issues
 Depression severe
 Axis II: Avoidant traits, Borderline traits
 Issues of discrimination
H. (cont.)
 Rapport essential
 Learning from him; learning about life lessons
 Masculinity issues, financial issues
 CBT for depression; polarized thinking
already improved
 Improve social support
J. (Caucasian male)
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Therapy does not always go well
Work injury caused depression/anxiety
Follow through difficult
Relationship issues
Cannabis dependence
Axis II, poor attitude
J. (cont.)
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Inform L and I, not taking therapy seriously
Hard to tell client about lack of effort
Countertransference issues
Boundaries; friended on Facebook
Chose not to learn CBT
E. (Caucasian male)
 White collared worker
 Attack incident at work caused PTSD
symptoms
 Nightmares and flashbacks; re-experiencing
events
 Social anxiety, depression, insomnia
 Rapport very good; trauma symptoms
diminished through CBT
E. (cont.)
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Education level low, hard to learn CBT
Self-worth issues
Family problems
Systematic desensitization for social
phobia
 IME problems
 Medication management issues
W. (Caucasian female)
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Blue collar work
Preexisting conditions aplenty
PD issues and PTSD
Rapport very difficult
Family problems
Claims manager issues; denial of
treatment
W. (Caucasian female)
 CBT for depression and anxiety difficult
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because of education level/feedback
Need to work through trauma history and
then proceed w/CBT
Improve relationships through assertiveness
training/empathy training
Depression severe; CBT helped
CBT and systematic desensitization helped
social anxiety
M. (Asian-American female)
 Blue collar work
 Preexisting conditions (PD features); now
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full blown PD
Hard to improve Borderline features with
pain issues
Emotional and difficult
Avoidant and paranoid of others
Social phobia concerns
M. (cont.)
 Problems learning CBT
 Systematic desensitizsation issues
 Effort issues
 Assertiveness training helpful
 Medication management issues
 Improving social support has helped mental
health
Questions?????