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Early Intervention in Disability Managment: Factors that Influence Successful Return to Work
by Henry Harder
Introduction
Disability Management is a relatively new field and is defined as "an active process of minimizing the impact of impairment on the individual's capacity to participate competitively in the work environment" (Shrey & Lacerte, 1995, p.5). Central to the practice of Disability Management is the concept of early intervention and a focus on psychosocial issues (Dyck, 2000). Disability Management does not have a well defined field of literature in general and very little that specifically addresses these concepts. This paper begins the process of defining this field of literature by drawing on historical and current literature from the fields of unemployment and psychology research, and explains what factors need to be addressed in order for early intervention to lead to successful return to work.
Unemployment
The inability to return to work post injury can be termed "traumatically induced unemployment". If an impairment, which results from an injury leads to unemployment, the consequences to the individual are the same as those of any other type of unemployment.
Researchers have examined the impact of unemployment on particular groups (e.g. Winefield, Tiggeman & Winefield, 1991). The literature also contains studies that demonstrate the importance of work in establishing a healthy identity (e.g. Kelvin, 1981; Schaufeli, 1988) and the resulting psychological impact of unemployment (Dooley & Catalano, 1988; Gurney, 1980; Winefield, Tiggeman, & Winefield, 1991). The impact of unemployment on persons with disabilities is similar (Borgen, Amundson & Biela, 1987). Acton (1981) identified four reasons why work is an essential goal for disabled persons: (a) they need the income derived from gainful employment, (b) nearly all cultures place a high value on work as a part of rich and complete life, (c) to form social relationships, and (d) it gives structure and discipline to living.
While the needs of persons with disabilities are similar to the general population, they do face special challenges in becoming employed (e.g. Tagalakis, Amsel, & Fichten, 1988). Stone and Sawatzki (1980) classified these factors into three specific areas: (a) numerous employment handicaps at the outset of a job search (e.g., lack of marketable skills, poor employment record), (b) management's misconceptions about what disabled persons bring to employment (i.e., lower productivity, higher absenteeism, higher accident rates, resentment of co-workers, negative attitudes, job site modifications, etc.), and (c) the employment interview process (mainly the interviewer's preconceived negative impressions). Thus persons with disabilities have the same needs for employment as the general population, but face barriers to employment that may alter their experience of both working and job search.
More recent studies such as the Quebec Task Force on Whiplash-Associated Disorders (Spitzer, et al, 1995) have shown the importance of psychosocial factors in resolving the effects of non-catastrophic injuries resulting in employment problems. Unemployment is a stressful event that has been shown to have negative psychosocial and health consequences (Liang, Dvorkin, Kahana & Mazian, 1980) and has been directly linked to depression, substance abuse and suicide (Peregoy & Schliebner, 1990). Finding ways to mitigate the reactions to this psychological distress is necessary if Disability Management is to be effective.
The unemployment literature reveals several important factors regarding the importance of work. Western industrialized and increasingly high technology societies place a great deal of value on gainful employment (Feather & Bond, 1983; Winegardner, Siminetti & Nykodym, 1984). People's work environments may well represent the most important group membership and focus of time in their lives. In fact, Uris and Tarrant (1983) suggested that the work group is more important than family, friends and community. Peregoy and Schliebner (1990) examined the effects of long-term unemployment and found that people look to the work place to meet their needs for primary social interaction, and as a surrogate family system.
Sullivan (1972) linked Maslow's (1968) hierarchy of needs with employment and found that most people use work as a way of satisfying personal needs ranging from survival to self-actualization. Erikson (1980) suggested that productivity in the workplace is a major contributor to healthy ego identity. If this productivity is reduced or eliminated through unemployment, for example, ego identity is strained and begins to disintegrate. This weakened ego identity can lead to feelings of inadequacy, loss, and doubting of one's self-worth and belonging. Erikson (1980) suggested that if this occurs, the individual can begin to stagnate and die.
Shelton (1985) reviewed studies on the social and psychological impact of unemployment. Based on her review, Shelton stated that "professionals who work with the unemployed should be prepared to deal with depression, anxiety, and loss of self-esteem in the individual. These emotions may directly interfere with the job-seeking process."
Application to Disability Management
The importance that work plays in a persons life is all too frequently forgotten. When a person is injured and off work they loose the structure, support and meaning that work gave them. Disability management providers need to remember how important this factor is and how quickly a person will move to replace it with something else, usually less productive, in order to have their needs met. Consequently, maintaining the connection with the workforce is of paramount importance during the entire recovery period.
Psychological Concepts
Depression
A commonly held belief is that unemployment leads to psychological depression. However, Frese and Mohr (1987) suggested that empirical studies have had difficulty demonstrating a causal relationship and that it may be more appropriate to say that: "Depressed persons who are inactive and pessimistic in their outlook will be unemployed much longer or will become unemployed more readily" (p.173). They further suggested that unemployment should not be viewed as one major life event, but rather as a life event that leads to a host of daily problems such as financial hardship and learned helplessness. Depression is rapidly becoming an epidemic in our society and is having a major financial impact on individual and employers and must become a focus of active intervention at the worksite (Wilson, Joffe, Wilkerson, 2000).
Application to Disability Management
Persons who are depressed and become unemployed stay unemployed longer. Persons who add injury to depression or vice versa will be very difficult to work with, and extremely reluctant to participate in return to work activities. It is therefore essential that disability management provision focus on the prevention of depression or the immediate treatment of depression should it begin to develop.
Learned Helplessness
The concept of learned helplessness (Seligman, 1975) is a useful framework through which to view the impact of unemployment. In fact Aronoff (2000) suggests that learned helplessness is so powerful that persons may become invalids because of this process. Learned helplessness is caused by repeated experiences of aversive, noncontrollable situations. A person caught up in learned helplessness exhibits passive, resigned, inflexible behaviour, linked to dysphoric feelings of depression brought on as a result of repeating these situations. The only escape from this condition is to exercise control over these situations.
Application to Disability Management
Perhaps an example can illustrate the importance of this concept. A claims adjuster requires a claimant to call in weekly and report on job search activities in order to receive wage replacement benefits. The person calls in faithfully and all is well. Then one week, the adjusters voice mail box is full and the person cannot leave a message. She tries several times and, as instructed, dials 0 to get assistance. The person who answers informs her that they do not take messages as everyone in the office has voice mail, and transfers her back to voice mail. This goes on for several weeks. She drops by the office but is told that she will not be seen unless she makes an appointment which she can only do by phone. The next week she receives a letter informing her that her benefits have been terminated for non-compliance. The end result of this scenario is a very frustrated person who is learning to be helpless in the face of her insurance carrier and is very likely to become actively non-compliant and probably litigious.
Locus of Control
Individuals' reactions to being unemployed may be affected by how they explain the source of their job loss. People with an external locus of control are more passive, generally achieve less (Lefcourt, 1976), and are more depressive (Prociuk, Breen & Lussier, 1976) than people with an internal focus. The locus of control construct refers to how people view themselves in conjunction with the events that befall them. The construct also encompasses the meaning that people give to the interaction between self and experiences (Lefcourt, 1976). Individuals with an external locus of control tend to perceive experiences as the result of causes outside of their behaviors and thoughts. Conversely, people with an internal locus of control make sense of experiences in terms of their own actions and thoughts. If people do not understand experiences as a result of their actions, then the experiences, either positive or negative, are not effective in altering their locus of control and therefore have no impact on their actions.
Gurney (1980) suggested that the kind of causal ascription made about unemployment by those who want to work, can have important implications on their well being. He further stated that "their attribution about the reasons for not having a job may play an appreciable role on either intensifying or mitigating their feelings of failure and self-worth" (p. 79). Causal attribution has seen widespread academic interest arising out of the work of Heider (1944), who stated that "when we have a disagreeable experience, or a pleasant one, we may locate its origin in another person, in ourselves, or in fate" (p. 358). Later Heider (1958) limited attribution to two factors, internal or external. In interpreting how people choose among possible causes, attribution theorists have identified two general categories. The first category posits the perceiver as a systematic analyst looking for covariation between a given effect and different possible causes (Kelley, 1967, 1971, 1973). The second categorizes the perceiver as tending to seek a single, salient explanation for a behavior (Jones & Davis, 1965).
Applying these two categories to predict the kind of causal attribution post-injury individuals would make about their experience is useful. The conclusion can be drawn that people in the second category would look for a single external cause, like their insurance carriers handling of their claim, and be unlikely to change their causal attributions unless the insurance carrier changed. The first category suggests that individuals would see many causes, apply the principles of consistency and distinctiveness (Kelley, 1973) and come up with internal reasons for their circumstances. An internal focus would make it easier for an individual to deal with their recovery and eventually return to work. However, Gurney (1980) stated that this may not be the case. He suggested that causal attribution and locus of control are largely independent of each other. For example, some people may believe themselves to be powerless to change their circumstances thus exhibiting an external locus of control. However, the fact that they have not returned to work when others have, may eventually lead them to see themselves as responsible for their predicament, an internal focus, and blame themselves for their situation. Gurney (1980) concluded that this particular combination of an internal attribution with an external locus of control may be the cause for the devastating impact that unemployment has on self-esteem.
In a more recent study Macleod and Macleod (1998) concluded that while internal locus of control was not necessarily psychologically adaptive, an external locus of control was maladaptive. These two factors, low self-esteem and an external locus of control, are important factors for individuals trying to return to work post injury.
Application to Disability Management
Furthering the example mentioned earlier, if the person experiencing learned helplessness is allowed to remain in that state they will soon shift to an external locus of control position if they were initially in an internal position. If they were already in an external position this will become more entrenched. This person will then take little or no responsibility for their own situation and will do very little to help themselves. Anyone coming along to help will soon be blamed as well and loose their effectiveness as a helper. Disability management interventions must focus on elevating self-esteem and on maintaining or achieving an internal locus of control.
Personal Construct
Since the 1950's there has been an increasing trend toward self-determination and personal planning with individuals taking control of their lives and accepting more responsibility for personal choices and life developments (Forster, 1985). An interest in the elements of personal decision making and planning has generated a great deal of academic and public attention on the concept of personal goal (Forster, 1985). Since establishing a personal goal is essential in career planning and job search, developments in the theory related to personal decision-making are relevant for designing programs to assist people to return to work. Forster concluded that "personal construct psychology would seem to be a theoretical framework well suited for the articulation and study of personal goals" (p. 261).
The fundamental unit in personal construct psychology is the "personal construct" (Forster, 1992). A personal construct is a transparent pattern created by individuals to organize the realities of their world. Individuals create constructs by deciding what theme is common in two or more events. This common theme is determined through a process of comparing and contrasting events until a similarity is found between at least two of these events. Personal constructs are developed over time, as a result of personal experience, and are formed into systems. Constructs provide a window or lens through which people perceive and understand events and also supply a mechanism for anticipating events and experiences. For example, suppose that a woman notices that her supervisor is more irritable at the end of the workweek than at the beginning of the week. She has a construct that enables her to recognize irritability. She may also use related constructs such as (a) more rest on the weekend, and (b) time to participate in relaxing activities, as she attempts to interpret her experience with her supervisor and anticipate future interaction. Forster (1992) selected the personal construct as the "primary conceptual unit for investigating the elicitation and articulation of a person's goals." (p.176)
Neimeyer (1992) and Kortas, Neimeyer and Prichard (1992) stated that the area of employment was accepted as a logical field of study for investigating the application of the concept of personal construct because Kelly (1955), the creator of personal construct theory believed that vocational development "is one of the principal means by which one's life role is given clarity and meaning." (p. 751) Construct systems developed by individuals in the course of their work experience are called vocational construct systems. Vocational construct systems might contain constructs like outdoor work, desk jobs, high wages and low salary. Individuals would use these constructs to organize and systematize their work experience and to anticipate future employment experiences. Gimenes (1990) assigned the label of vocational development construct to the interaction of: - (a) the factors which motivate people to form vocational construct systems,
- (b) the elements which prevent people from forming vocational construct systems, and
- (c) the factors which trigger specific employment decisions.
Since vocational development is based on work experience and all previous vocational decisions, Gimenes concluded that the construct clearly indicated that selecting an occupational goal is a complex process that takes time.
Evidence of some relationship between level of integration in personal construct systems and decision-making has implications for the design of a treatment program that includes the identification of skills based on previous experience and the selection of new goals. Successful return to work post injury may require higher levels of integration of personal construct systems. All people, but particularly individuals faced with the reality of having to make substantial efforts in order to return to work, must reorganize their personal construct systems to incorporate both the experience of injury and recovery and the personal constructs that will guide their decision-making throughout their treatment and return to work process.
Application to Disability Management
Someone who is employed has a personal construct of themselves as a worker. When they are injured this begins to change to that of an injured worker, and then if all goes well, to a recovering worker and eventually a recovered back at the job worker. All to frequently as a result of lack of intervention or long delays in intervention, the construct changes from worker to benefits recipient to angry benefits recipient to cut off of benefits angry individual to advocate for rights to no worker construct what so ever. Early interventions stops this progression and keeps the focus on work and enables the worker to maintain their worker personal construct.
Conclusion
Early intervention is seen as the holy grail of Disability Management. However, few people understand what makes early intervention work. If we do not pay attention to the factors that influence the people who are off work due to injury, early intervention is destined for failure. Just being quick solves nothing. Being quick to act, to stay in touch, to be accessible, the ensure the continuity of benefits all play a part in preventing depression, in preventing the slide form being in charge of ones own life to helpless, the deconstruction of the construct of worker and the failure of the system to assist an injured workers to reestablish their employment.
The following factors make early intervention work:
- Recognize the importance of work and the valuable role it plays in peoples lives.
- Identify and treat psychological issues, specifically depression.
- Avoid Learned Helplessness.
- Keep or create an internal locus of control.
- Keep the worker personal construct in tact.
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Submitted by
E-Mail: Henry Harder, University of Northern British Columbia
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