According to several studies, somewhere between 25% to 45% of workers with an accepted workers compensation claim for a physical injury develop a secondary psychological condition. 

That’s a pretty large proportion of workers who experience a physical work injury. 

Yet studies also show that most workers who report psychological distress or mental health issues don’t receive mental health treatment. This is mostly due to the barriers to accessing mental health services in Australia generally, particularly since the pandemic which has significantly increased demand.

So what can we do better to identify and support workers who are risk of developing those conditions, and to prevent them from occurring in the first place?

In this webinar from the Healthy Working Lives Research Group — 'Secondary psychological conditions in workers compensation schemes' — Professor Alex Collie, Director of the Healthy Working Life Research Group, and Dr Dielle Felman, Consultant Psychiatrist, discuss what we can do better to identify and support workers who are risk of developing those conditions, and to prevent them from occurring in the first place.

What do we mean by secondary psychological injury?

Professor Alex Collie describes secondary psychological injuries as a range of mental health problems in workers with physical health conditions — from clinically diagnosed mental health disorders to other ‘subclinical’ mental health issues — that show up some time after a person suffers and makes a claim for a physical injury or illness.  

These conditions prolong RTW and have serious negative health, family and social and financial consequences for workers. They can also be complex to treat and support and are costly for work injury schemes. 

So there are good reasons to try to prevent secondary psychological injury. The good news is that by understanding who is at risk of developing secondary mental ill health we can put strategies in place to reduce the risk.   

Who is at risk?

Professor Collie says the risk of developing a secondary psychological injury is a combination of both predisposing factors (things that are present before the claim is made) and enabling factors (things that are present after the injury or claim). 

Predisposing (or ‘individual’ factors) are the things that might make someone more vulnerable to psychological ill-health, such as a history of mental health conditions, poor general health or comorbidities or other stressful life situations. The include personal internal resources (like coping strategies, resilience, personality) and external resources (like their financial situation and what kind of family and social support they have around them), 

If we want to focus on prevention, it’s really the enabling factors we should focus on. They are the things we can most change or influence. These are what Dr. Dielle Felman calls ‘system factors’:

• the way we run and manage our work injury scheme processes
• worker perceptions of fairness, including interactions with insurance case managers and employers
• a sense of being believed or not and the repeated cycle of needing to prove their disability (which can become a self-fulfilling prophesy). 

Other factors that can influence the rate of secondary mental distress or ill health include concerns about making a claim, treating practitioners providing ‘passive’ rather than active treatment and certifying workers unfit to return to work for prolonged periods.

Dr Felman also points to ‘injury’ factors that contribute to psychological distress in people with musculoskeletal injuries. Loss of function due to pain, medication or surgery means that people can’t do the things that often act as protective factors against anxiety and depression. This can lead to ‘pain catastrophising’ and avoidance behaviours where the worker avoids doing certain things for fear they will make the pain worse, which in turn leads to a more restrictive life. 

We need to break this vicious cycle

Dr Felman describes a common reinforcing cycle that happens after a worker suffers a physical injury and the impact that has on their recovery. 

It goes like this: Pain and reduced functioning from the injury means that the person starts to avoid doing things—both work and social and other activities. Their mental health starts to decline because of the pain, reduced functioning, lack of exercise and lack of meaning, purpose and joyful pursuits. They tend to spend more time preoccupied with their injury and ruminating on their pain and disability. They might feel anger, or as their coping mechanisms break down they may increase alcohol use or self-medicate. They may catastrophise about their injury (‘it will never get better’), generalise (‘the whole world is unsafe’), and feel anxiety, hopelessness, persecution, paranoia, mistrust and a sense of injustice. Often what happens is a deteriorating physical and mental state which is much worse than the initial injury.

So what do workers need, and what can we do to reduce the risk?

Professor Collie and Dr Felman outline a range of things that injured workers need, and that insurers, employers and treating practitioners can do, to reduce the risk of secondary psychological injury:

Focus on symptomatic and functional recovery

• Improve screening and service delivery in the course of a work injury claim so that workers can access the right treatment at the right time.
• Promote activities that can support recovery — such as maintaining social supports and activities, doing things that provide enjoyment, meaning and purpose.

Reduce some of the risk factors that are associated with declining mental states

• Help workers engage in rather than avoid activities, so they are not sitting at home with nothing to do, ruminating on their disability and losing confidence and self-esteem.
• Remove as much of the adversarial nature of the workers compensation process and injustice as we can.

Focus on a way forward

• Help workers to recognise when their mental health is suffering and access support pathways.
• Normalise that having a psychological issue is common after an injury and destigmatise any secondary mental ill health.
• Check in on them and let them know how they can access support.

Insurers can: 

• build trust — to show that the insurer and workplace have their best interests at heart
• develop a vocational goal or plan from day one—expand the focus from just getting the person back to work to the wider goal of helping them achieve their best in all areas of life
• refine the information they receive from treating doctors in certificates of capacity and reports. (Dr Felman suggests including a box for ‘fit for rehabilitation’ to communicate when the worker is ready to start doing activities that are focused on recovery before they return to work)
• educate claims staff about the incidence and signs of secondary psychological injury.

Employers can:

• try to keep worker at work in some capacity, to foster the feeling that they can contribute and add value
• skill managers so they can have positive interactions with the worker and take time to listen to issues as they arise
• skill managers up to identify signs of declining mental health and show empathy and understanding — what may look like bad behaviour may not just mean that they are struggling psychologically.

Treating practitioners can:

• avoid passive treatment
• make a double appointment so they have the time they need to focus on the paperwork, management and treatment
• screen for symptoms of psychological illness, or predisposing factors for mental health concerns, and normalise, educate and create pathways for help.

Everyone can:

• humanise the injured worker! — see them as a person and think about what they might be feeling and going through
• take psychological distress at face value until proven otherwise, validate how the worker is feeling and normalise secondary psychological injury rather than stigmatise it
• show empathy, interest, understanding and support
• provide psychoeducation at the start of the claims process (or in the workplace before injuries or illness occur) so that workers know that this can be a challenging time for everyone, what signs to look out for and what pathways for support exist. 

Finally, Professor Collie and Dr Felman say we need to try to improve access to mental health services, and perhaps part of the solution is to widen the net about who can provide that treatment. That may need to include social workers and mental health nurses, not just clinical psychologists.