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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 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 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 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 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 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 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 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 Blue collar workers Language Rapport Directive vs. Non-directive Typologies cont. White collar workers Language Rapport Directive vs. Non-directive Older Patients vs. Younger Patients Rapport issues Directive vs. Non-directive Narrative therapies Educating you Number One Work-Injured Patient Typology Depression, anxiety, anger, somatic pain 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 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 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 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 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 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 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 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 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 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, 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 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 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 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 (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 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.) 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 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) Therapy does not always go well Work injury caused depression/anxiety Follow through difficult Relationship issues Cannabis dependence Axis II, poor attitude J. (cont.) 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.) 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) 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 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 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?????