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The ACOEM Guidelines, now presumed correct under
California law [see Labor Code §4600],
recommend that Primary Treating Physicians refer injured workers for psychological
consultation whenever “no specific injury” has occurred and/or pain
complaints continue “after the acute lesion should have healed” (p.
105). In order to prevent psychological factors from complicating an injured
worker’s subjective experience of pain (and
possibly precipitating a chronic pain syndrome),
the psych referral should be made at the earliest
possible time.
The ACOEM Guidelines recommend psychological consultation whenever complaints
of pain have failed to improve after six weeks of medical treatment, as well
as whenever it is determined that a psychological reaction to pain may be contributing
to the impaired functioning or psychiatric factors may be interfering with an
applicant's capacity to benefit from medical treatment. The Guidelines recommend
psychological involvement in order to:
- Promote the injured worker’s
continued involvement in as many activities of daily
living as possible (p. 109);
- Limit the degree to which “central
nervous system factors” (such as feelings of hopelessness,
unconscious motivation to avoid unpleasant and/or stressful
circumstances, distorted perspective, anxiety, helplessness,
and depression-related lethargy) distort the injured worker’s
subjective perception of, and response to, physical symptoms
(p. 105);
- Prevent
psychological factors (such as feelings of hopelessness,
desire to avoid any pain, and depression-related lethargy)
from leading to decreased activity and deconditioning,
thereby increasing pain level (p. 105): and
- Prevent the medical
treatment from becoming palliative rather than rehabilitative,
over-relying on opioid and/or muscle relaxant medications
that may actually increase overall impairment.
As soon as any delay in recovery is
observed, ACOEM recommends “judicious involvement of” and “close
communication” with a consulting psychologist in order
to “decrease the likelihood that [the injured worker]
will go on to develop chronic pain” (pp. 107, 109).
In such cases, ACOEM recommends an interdisciplinary rehabilitation
approach that emphasizes functional restoration rather than
relief of pain, and that promotes continued involvement in
as many activities of daily living as possible.
The ACOEM Guidelines also point out that scientific research
has demonstrated that “multidisciplinary care is beneficial
for most persons” and “likely should be considered
the treatment of choice for persons who are at risk” of
developing a chronic pain syndrome (p.114). They also indicate
that research has shown that multidisciplinary treatment including
psychological consultation is “superior to conventional
physical therapy alone, had benefits that persisted over time,
and was beneficial in improving return to work and decreasing
use of healthcare” (p. 114).
The goal of psych consultation in cases of prolonged pain,
therefore, is to identify and manage psychosocial factors that
may be contributing to the continuing pain. Cognitive-behavioral
psychotherapy may be required to reorient an applicant to a
rehabilitative approach, and psychotropic medications may in
some cases be necessary to provide the injured worker with
sufficient emotional stability, energy, and mental control
to reasonably participate in their own treatment.
Chapter 15 of the ACOEM Guidelines also recommends mental health
treatment in cases where:
- The prescription of psychotropic
medication is indicated (p. 388);
- "Stress management
techniques"—such as relaxation training or biofeedback
therapy—are indicated (pp. 399-400);
- "Behavioral
techniques"—such as assertiveness training or conflict
resolution—are indicated (p. 400);
- "Cognitive
therapy" or "stress inoculation therapy" is
indicated (pp. 400-401); and
- Returning an industrial patient
to unrestricted work without treatment would “lead to
increased stress, with resultant depression, insecurity, and/or
jeopardized employment” (p. 404).
If every Primary Treating Physician
were following the ACOEM Guidelines with respect to psych
referral, there should be fewer cases in which disability
arises due to chronic pain. On the other hand, there might
also be fewer cases in which compensable consequence psych
injuries go unidentified.
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Workers’ compensation regulations
currently specify that the Global
Assessment of Functioning (GAF) Scale
is
to be used to generate a Whole Person Impairment (WPI) percentage
which is then adjusted for age, occupation, and Future Earning
Capacity [see Schedule
for Rating Permanent Disabilities,
at p. 16]. Many psych evaluators, however, are reluctant to
offer GAF scores below the range of “Mild” (61
to 70). A careful reading of the DSM-IV criteria for GAF scoring
reveals, however, that whereas a great many injured workers
fall into the 61 to 70 GAF range, many others merit GAF scores
in the “Moderate” range
(51 to 60) or lower.
According to DSM-IV, injured workers qualify
for a GAF score of 61 to 70 when they are “generally
functioning pretty well” and have “meaningful interpersonal
relationships,” but also have “some mild symptoms
(e.g., depressed mood and mild insomnia)” or they are
experiencing “some difficulty in social, occupational,
or school functioning.” This is not a particularly difficult
standard to meet. In fact, it may describe most people.
In order to qualify for the GAF range of 51 to 60, an injured
worker must be experiencing “moderate symptoms" (e.g.,
flat affect and circumstantial speech, occasional panic attacks)
or must display “moderate difficulty in social, occupational,
or school functioning (e.g., few friends, conflicts with peers
or coworkers).” It is my experience, however, that even
applicants who are experiencing frequent and relatively severe
panic attacks (or who are experiencing conflicts with almost
everyone) tend be inappropriately categorized in only the “mild” range
psychiatric dysfunction.
DSM-IV specifies that in order to qualify for the GAF range
of 41 to 50 (“Severe”) an injured worker must be
experiencing “serious symptoms" (e.g., suicidal ideation,
severe obsessional rituals, etc.) or display “any serious
impairment in social, occupational, or school functioning (e.g.,
no friends, unable to keep a job).” Anyone who has provided
psych care to a large number of injured workers will have encountered
quite a few with musculoskeletal injuries that have caused
them to become so hopeless and so persistently distressed that
they qualify for the 41 to 50 GAF range. In my experience,
however, even injured workers who have been so seriously injured
that they have become hopeless and developed recurrent suicidal
ideation are frequently categorized above a GAF of 50.
Rarely is an injured worker's GAF rated as below 41, although
there certainly are some who would qualify for lower scores
based upon the DSM-IV criteria. In order to qualify for the
31 to 40 GAF range, an injured worker must have developed either “some
impairment in reality testing or communication (e.g., speech
is at times illogical, obscure, or irrelevant)” or must
display “major impairment in several areas, such as work
or school, family relations, judgment, thinking, or mood (e.g.,
depressed man avoids friends, neglects family, and is unable
to work…).” This latter description is actually
not uncommon in the more severe cases of industrial injury.
Yet rarely is a GAF rating below 41 applied to an injured worker.
Even the GAF range of 21 to 30, as described by DSM-IV, is
appropriate for those injured workers who have developed psychotic
disorders in reaction to the emotional stress created by their
industrial musculoskeletal injuries. DSM-IV specifies that
a GAF score in the 21 to 30 range is indicated when an injured
worker’s “behavior is considerably influenced by
the delusions or hallucinations (e.g., sometimes incoherent,
grossly inappropriate, suicidal preoccupation)” or
the injured worker has developed “inability to function
in almost all areas (e.g., stays in bed all day, no job, home,
or friends).” In my experience injured workers meeting
these descriptions typically receive GAF scores in the 41 to
50 range.
Whether the result of a reluctance to be deposed, or possibly
fear of alienating an insurance carrier, psychiatric and psychological
evaluators seem to be reluctant to assign extremely low GAF
scores to injured workers, even when merited by DSM-IV criteria.
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On April 19, 2004, Labor Code §4663
was amended to require that apportionment of permanent
disability be based upon causation, and Labor Code §4664
was added to require apportionment to any prior comparable
disability determination. At the same time, Workers’ Compensation
Regulations (Title 8, CCR, §10606) and WCAB case
law established by the Escobedo decision require that
apportionment of permanent disability be based on pertinent
facts, framed in terms of reasonable medical probability,
supported by reasoning derived from an adequate examination
and history, and not speculative.
Unless a prior psychiatric
disability rating exists, or there is clear evidence
of chronic pre-existing psychiatric impairment, it is
often impossible for a psychiatrist or psychologist to
apportion psychiatric disability without being unreasonably
speculative. This is especially true in cases in which
the injured worker has denied that non-industrial factors
have played any role in the causation of their emotional
distress. If the injured worker estimates that a non-industrial
stress played a 25% role in the causation of the psychiatric
condition, this provides the psych evaluator with some
evidentiary basis for apportionment. If the injured worker
denies any non-industrial causation, the percentage of
apportionment offered by the psych evaluator can appear
entirely arbitrary and can be quite difficult to defend.
It is not so much the decision to apportion that is difficult
to defend, as the exact amount of the apportionment,
a percentage that often appears to be entirely speculative.
In my opinion, it is also improper to apportion psychiatric
disability to personality traits. Unlike Personality
Disorders, personality traits do not represent character
pathology or psychiatric disability. Everyone has personality
traits. Apportioning psychiatric disability to a personality
trait would be equally as reasonable as apportioning
musculoskeletal disability to a physical trait, such
as being short or left-handed.
In my opinion, it is also improper to apportion psychiatric
disability to childhood trauma. Childhood trauma can
be the cause of later-life psychiatric disability only
if it has caused life-long psychiatric disturbance that
has lasted into later-life. In that case, the apportionment
would appropriately be made to the life-long psychiatric
disturbance, not the childhood trauma.
I also find it to be unreasonable to apportion psychiatric
disability to Alcohol or Substance Abuse Disorders that
have been in sustained remission for many years. Although
prolonged abuse of alcohol and/or drugs could certainly
result in chronic injury, becoming “clean and sober” is
an event that is usually perceived as a triumph, and
the psychiatric effects of the substance abuse typically
resolve within 18 months.
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There are so many unintended
negative consequences to the institution of utilization
review in the workers’ compensation system that
I don’t know where to begin. One problem is that
utilization reviewers typically seem to view their job
as denying everything that can conceivably be denied.
Sometimes they find elaborate justifications for their
denials, but that frequently results because the industrial
insurance carrier has supplied the reviewer only with
the request for authorization and none of the prior medical
reports about the patient in question. This is how my
patient who has been wheelchair-bound for 12 years was
denied authorization for aquatherapy (virtually the only
type of physical exercise available to him) on the grounds
that prior aquatherapy had not restored his ability to
walk.
Another deleterious aspect of utilization review is the “three
session” authorization. The physician prepares
and submits a request for authorization. A utilization
reviewer then contacts the physician for a “peer-to-peer” in
which the physician is required to explain the details
of the injured worker’s case, the treatment that
has already been provided, the treatment response obtained,
and the medical necessity of the treatment for which
authorization has been requested. Some utilization reviewers
seem friendly and reasonable; others are obnoxious and
insulting. In either case, however, the reviewer typically
authorizes only a small part of the treatment requested,
requiring the physician to repeat the process all over
again a month or two later. Multiply this process by
40 to 100 patients, and the physician has little time
for anything but preparing authorization requests and
talking with reviewers on the telephone. For many physicians,
treating injured workers in California has become a demoralizing
proposition.
In my experience, about half of my requests for authorization
go unanswered. Although the industrial insurance carrier
may be lawfully responsible for the treatment requested
in such cases, most physicians will not provide consultation
or treatment without pre-authorization. As a result,
by simply ignoring treatment authorizations an industrial
insurance carrier can so frustrate the injured worker
and the treating physician that a pervasive sense of
hopelessness develops about the industrial injury claim.
My worst experience with utilization review occurred
when I was awakened at 5:05 a.m. by a telephone call
to my emergency cell phone number. The utilization reviewer,
who was calling from the East Coast where it was 8:05
a.m., advised me that this was my one and only opportunity
to explain why my patient needed the treatment I had
requested. He seemed completely unfazed by the fact that
he had awakened me so early and at home in my bed (and
without my false teeth, which makes my speech difficult
to understand). At least that has not happened again.
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Winning
the Disability Challenge: A Practical Guide to Successful
Living (2008, New Horizon
Press, P.O. Box 669, Far Hills, N.J., 07931) is a book
I published last year. The book, which was recently named
a finalist in the competition for the National Best Books
Awards of 2008, offers understanding, inspiration, hope,
practical guidance, and an alternative perspective to
those coping with disabling chronic pain and/or impairment.
It is designed to either help an injured worker develop
a self-rehabilitation plan, or facilitate the efforts
of a therapist who is trying to improve patient motivation
and perspective, and promote self-improvement activity.
Winning the Disability Challenge presents an “empowerment” strategy
that employs aspects of rational therapy, positive psychology,
and 12-step recovery philosophy. The book’s Introduction
makes it clear that the distressing perceptions and emotions
that often accompany disabling injury represent an understandable
and normal human reaction, but that they can be successfully
managed if approached in a constructive manner. The injured
worker is led on a search for reasons to be grateful
and hopeful, sources of inspiration, and the opportunities
that almost always exist to improve him or herself and
the circumstances of his or her life. The book provides
tools that assist the injured worker to better structure
each day so as to optimize self-care, physical conditioning,
mental exercise, spiritual growth, creative and assertive
self-expression, constructive activity, and/or personal
relationships.
The book sets forth the goal of achieving greater peace
of mind by focusing energy and attention on life’s
simplest moment-to-moment decisions, and “turning
over” and “letting go” of anger about
past events or fear of what might occur in the future.
The reader is urged to seize control over those aspects
of life that might be influenced, and resist the temptation
to helplessly “spin wheels” over those disturbing
aspects of life that no individual can change. The book
emphasizes the importance of staying in, and returning
to, the current moment, the only time in which any constructive
action is possible. The philosophy presented is the crux
of recovery from any loss or trauma, and promotes the
rehabilitative approach recommended by ACOEM.
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Dr. Tholen has been evaluating
and treating injured workers in the Long Beach area for
more than 20 years. He has been a QME since the inception
of that designation in 1992. He is also author of Winning
the Disability Challenge: A Practical Guide to Successful
Living (2008, New Horizon Press, P.O. Box 669, Far Hills,
N.J., 07931), a new book that offers hope and direction
to disabled workers and can be effectively employed in
their rehabilitation and psychiatric treatment. The book
was recently honored as a finalist in the competition
for the National Best Books Awards of 2008.
To order
this book, click here. |
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For
Dr. Tholen’s CV and contact information,
click
here. |
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