Starwood Analysis September 9, 2002

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A Cognitive Behavioral Model to Enhance Return
to Work Outcomes Kristin Tugman, MS, CRC,
LPCDirector, Corporate Program
DevelopmentCarrie Palmer, MEd, CRCDirector,
Clinical and Vocational Services
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Presentation Overview

• The Psychology of Return to Work
• At Risk Impairment Groups
• Incidence Clinical Characteristics
• Symptom Amplifiers The Disability Mind-Set
• Strategies for Prevention Management
• The Basics within the Employer Organization
• A 7 Step Model to Enhance Return to Work
  Outcomes
• Who should use this Model? And How?
• Tracking Impact
• Discussion

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The Psychological Perspective

• There is psychology involved in a return to work
  attempt for every injury or illness.

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The Psychological Coping Process A Daily,
Hourly Event

• A Cognitive Appraisal of the Event and Associated
  Events
• A Threat, Loss, Danger, Attribution/Cause
• An Affective/ Emotional Response to the
  Perceived/Real Threat
• Shock, Fear, Anxiety, Worry, Anger, Embarrassment
• Defend Protect
• Denial (beneficial/pathological), Secondary Gain
• Locus of Control
• Internal vs. External, Learned Helplessness,
  Stigma
• Timing, Scope, Severity and Permanency of
  Disruption (threat)
• Immediate, Short term (lt 6 months), Extended (gt 6
  months)
• Cognitive Distortions The Big 3
• Premature Conclusions, Dichotomous Thinking,
  Catastrophization

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Interventions (Preventing the Disability Mind-Set)

• Adjustment, Adaptation, Acknowledgement
  Acceptance
• Where do we begin? - What should we expect?
  Where do we end?
• Educate, Plan, What Ifs
• Who steps up to be the coping coach?
• Waiting for the Divine?
• Does religious faith and practices make a
  difference?
• Incremental Steps Patience
• Delayed gratification, early mobilization and
  clear reinforcement
• Hopefulness, Hopelessness Helplessness How,
  not When!
• Where do they begin, how am I doing and to what
  end
• Its all in my thinking?
• But my back hurts?

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Guidelines to Moving Forward

• Understand that change is natural
• Significant degrees of quick change are the
  threat
• Incremental change is the goal
• Faith, hope and realistic expectations facilitate
  the perception and capacity for success
• Be aware of the individuals readiness to change
• The silent saboteur in the coping process is
  Ambivalence. Ambivalence is the middle ground
  between perceived costs and benefits to change.
  The result is a sense of being emotionally stuck.
  Being stuck can be interpreted in many ways by
  the outside observers.

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At Risk Impairments

• Depressions (Bipolar - Unipolar - Post Partum -
  Reactive)
• Fibromyalgia
• Chronic Fatigue Syndrome
• Irritable Bowel Syndrome
• Multiple Chemical Sensitivity
• Repetitive Stress Syndrome
• Back Pain/Injury
• Heart Disease

Functional Somatic Syndrome
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Clinical Characteristics

• The clinical nature of these diagnosis groups
  leads to a high risk of extended disability
  durations.
• Explicit and elaborate self-diagnoses
• Not responsive to standard medical care
• High rates of co-occurrence - by MD specialty
  alignment
• Subject to stigmatization disability cynicism
  by family, friends, co-workers claims managers
• Self-perpetuating self-talk cycle of disability
• Things will get worse
• The belief that a serious disease exists
• Litigation and compensation are prominent
• Portrayal of the condition as catastrophic
• All encompassing in the persons life their
  identity.

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Incidence Clinical Characteristics

• Depression
• 10 of working population 9 of all absences
  from work
• Triple digit growth in claims submissions
• 12 Billion in lost work days
• Estimated 15 - 20 of total corporate health
  care costs
• Clinical depression seen 21 female to male
• Manic depression seen 11 female to male
• Person less capable of acting assertive in
  care, stuck, fatigue,
• low self confidence, symptoms not
  recognized by patient,
• internal focus, socially stigmatizing,
  access to care is limited
• Primary care management may not be effective
  with
• a solution that requires time and focus to
  achieve complex

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Incidence Clinical Characteristics

• Fibromyalgia
• 2 of population 20 of Rheumatology practice
• Defuse pain, multiple tender points,
  depression,
• sleep disorders, invisible symptoms
• Performance tasks, memory and concentration
  deficits
• Chronic Fatigue Syndrome
• 112/100,000 in medical practice

Fibromyalgia Triangle
Chronic Pain Sleep Disruption
Depression
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Incidence and Clinical Characteristics

• Back Injury
• ? Over 80 of adults have experienced low back
  pain.
• ? A symptom, including discomfort of the
  lumbosacral area of the back, including radiating
  pain and/or numbness into the legs, hips and
  buttocks. Low back pain often has unknown causes
• ? Direct cost estimated to be over 30 billion
  dollars annually.
• Psychological factors play a major role in not
  only the onset but, also, in the progression to
  chronic disability. The literature also
  indicates that low back pain historically has led
  to a fear of activity.
• Interventions for workers in the early stages of
  disability are a combination of active
  rehabilitation, progressive exercise, working
  toward overcoming fear-avoidance beliefs,
  encouraging self-care, and intervention at the
  workplace to assist patients in making an
  incremental return to work.

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Incidence and Clinical Characteristics

• Heart Disease
• ? 4 of the population inflicted with heart
  disease.
• ? A heart attack results in damage to the heart
  wall caused by the formation of a thrombus (blood
  clot) or plaque (cholesterol build-up) that has
  developed slowly within a coronary artery
• ? After an AMI people are often afraid of relapse
  but, according to the MDA, 90-95 of individuals
  who experience an AMI leave the hospital.
• ? According to the American College of Cardiology
  Foundation (1999), cardiac rehabilitation is
  often the treatment of choice during the recovery
  period.

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Economic Burden of Illness

• Hypertension (392 per eligible employee per
  year)
• Heart Disease (368)
• Depression and other Mental Illnesses (348)
• Arthritis (327)
• Presenteeism costs were higher than medical costs
  in most cases and represents 18 to 60 of all
  costs for the 10 health conditions studied
• Total cost of health, absence, short term
  disability and productivity losses was
  synthesized

Goetzel et al. JOEM, 2004 46(4)
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Symptom Amplifiers (Secondary Gain/Motivation)

• The belief that one is sick - Application for DI
• The emerging disability mind - set
• The reinforcement of sick role - Awarding of DI
• Stress distress (Fear and Avoidance)
• Greater/new job demands with incongruent skills
• Perceived loss of control in job
• Real or perceived job insecurity
• Less camaraderie or social isolation with
  co-workers
• Fear of the unknown leads to avoidance
• Fear of relapse/re-injury
• Disability insurance paradox (DIP)
• Anyone who invests great amounts of time in
  proving
• they cannot work will not work.
• Iatrogenic disability
• Excessive medical testing treatment
• Evidence based medicine
• Physician reinforcement of sick role
• Advocating

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The Emerging Disability Mind - Set

• Declining Performance
• ShameGuilt
• Treatment
• Advocacy
• Defending the Impairment
• Disability InsuranceReinforcement
• Identified PatientIdentity
• EARLY INTERVENTION

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Lost Time Management Aligning Corporate
Strategies

• Core - Compliance
• Information and data management Know who is
  off work
• Plan design aligned with corporate lost time
  expectations
• Timely, accurate and consistent claims
  reporting and administration

• 2nd Level - Stay _at_ Work
• Establish Supervisor functions, expectations
  incentives
• Manage job performance problems
• Build work site accommodations transitions -
  SAW/RTW

• 3rd Level - Return to Work
• Influence/Direct employees lost time
• Develop medical support for SAW/RTW
• Re-engage employee - How?...Preparation

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Preparation A 7- Step Cognitive Behavioral
Intervention

• Validate the Persons Feelings and Concerns.
• Baby Steps
• ABCDE Technique
• Five Fears of Return to Work
• Relapse Prevention
• Boundaries
• Work Adjustment

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Preparation Step 1

• Validate the persons feelings and concerns.
• Recognize that you have an illness not a
  character defect.
• Express Empathy
• Sense of understanding and acceptance of the
  person's feelings and perspective.
• There is no judgment, blame or criticizing.
• It is not an agreement or endorsement of how the
  person feels but only recognition that this is
  how it is for that person.
• Build a relationship that includes trust.

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Preparation Step 2

• Baby Steps.
• Incremental steps toward recovery
• Focus on what is possible
• Slowly increase activity based on medical
  capacity
• Activity promotes recovery

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Preparation Step 3

• ABCDE Technique.
• Cognitive Restructuring
• A Activating Event
• B Belief or Thought about the Activating Event
• C Consequence of automatic Belief about A
• D Dispute
• E Effect what would have happened had D been
  the automatic thought?

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Preparation Step 4

• Five Fears of Returning to Work.
• Name 5 of your biggest concerns associated with
  going back to work.
• What if I cant do it?
• What if I get sick again?
• What do I tell my co-workers?
• Are these fears rational?
• Make a plan.

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Preparation Step 5

• Relapse Prevention.
• What if I get sick again?
• A fear of relapse often leads to the avoidance of
  RTW
• Plan
• What is it like to be well?
• What is it like to be sick?
• What are the early warning signs of a relapse?
• What is my concrete plan if my warning signs
  appear?

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Preparation Step 6

• Developing Appropriate Boundaries.
• What type of work environment will you return to?
• How do your co-workers/supervisors perceive you?
• What are your realistic limitations?
• How can you make your abilities and work
  expectations congruent?

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Preparation Step 7

• Work Adjustment.
• Work adjustment outside of the employer
• Transitional Return to Work within an employer

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Transitional Work Model
Transitional Work
Transitional Work
Absence from Work
Agreed Upon Accommodations
Absence from Work
Stay at Work (preserve productivity)
Return to Work (restore productivity)
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Transitional RTW Pathways
RTW Planning tool generates communication
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RTW Options
Tool identifies options to transition employees
back to work.
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Sample Transitional Return to Work Plan Back
Injury
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Sample Transitional RTW Plan - Depression
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Who should use this model? How?

• Employer Human Resources departments
• Develop pathways for RTW in advance of an absence
  from work
• Communicate with the employee regularly
• Utilize pre-determined pathways to write-up
  transitional RTW plans
• Partner with Occupational Health where possible
• Partner with EAP where possible
• Train managers and serve as a resource to them
  regarding RTW policies and procedures
• EAP organizations
• Serve as a RTW preparation resource for employer
  human resources department
• See the employee regularly in order to implement
  7-step preparation model
• Partner with human resources to implement
  transitional RTW plans

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Who should use this model? How?

• Disability Management Vendors Vocational
  Rehabilitation Professionals
• Work with Employer to ensure RTW and lost time
  prevention foundation exists
• Communicate with the EE regularly
• Use 7-step indicators to assist in preparing an
  employee for RTW
• Partner with the Employees physician
• Use Pre-determined Transitional RTW pathways in
  order to write appropriate TRTW plans
• Partner with the Employers human resource
  department in order to implement the TRTW plan
• Actively track outcomes

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Tracking Outcomes

• Decrease duration of lost time claims
• Increase in successful returns to full
  productivity
• Decrease in repeat lost time claims
• Improvement in employee morale and presenteeism

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Case Scenario

• 50-year-old Elementary School Teacher on long
  term disability due to Fibromyalgia Syndrome with
  secondary depression. The individual voiced
  anxiety and resistance related to the idea of
  returning to work.
• Step 1
• A vocational counselor worked w/client and used
  the first step in the 7-step model - Led to
  additional work around increasing daily activity,
  as the individual was anxious about challenging
  herself both mentally and physically.
• Step 2
• The client began with the baby step exercise and
  slowly increased her daily tasks until she felt
  comfortable participating in medically approved
  physical activity.
• Step 3
• The client began cognitive exercises in order to
  assist in improving memory Led to enhanced
  confidence
• Step 4
• The client explored fears related to return to
  work Led to vocational counselor addressing
  fears and a plan was developed for each fear.

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Case Scenario Contd
Fear Plan
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Case Scenario, contd

• Step 7, work adjustment
• The clients work adjustment included
  coordinating a special assignment with her
  school, allowing the client to acclimate herself
  back into the work environment.
• As a result of the clients participation in the
  7 step activities, she gained enough confidence
  in both her psychological and physical capacity
  to ultimately set a return to work date.

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International Discussion Points

• STD and LTD Benefits
• Healthcare
• Laws related to worker discrimination and job
  protection
• Resources

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7 Step Model Indicators
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Suggested Bibliography

• New Mental Health Care Market, Health Affairs,
  Project Hope. September/October 1999, Volume 18,
  Number 5, 1999.
• Hannan, Anderson, Pincus, and Felson,
  Educational Attainment and Osteoarthritis
  Differential Associations with Radiographic
  Changes and Symptom Reporting. J Clin Epidemiol.
  Vol. 45, No. 2, pp.139-147, 1992.
• Hadler, Nortin M. Fibromyalgia, Chronic Fatigue,
  and other Iatrogenic Diagnostic Algorithms.
  Postgraduate Medicine. Volume 102.August 1997.
  Pp.161-177.
• Barsky, Arthur J., M.D., and Jonathon F. Borus,
  M.D. Functional Somatic Syndromes. Annals of
  Internal Medicine. June 1999.Volume 130.
  Pp.910-921.
• Fibromyalgia, Chronic Fatigue Syndrome and
  Repetitive Strain Injury Current Concepts in
  Diagnosis. Management , Disability and Health
  Economicsby Chalmers, Littlejohn, Salit and
  Wolfe, Editors Haworth Medical Press, 1995
• Tugman, K. and Palmer, C., The Fear of Return to
  Work A model to enhance return to work
  outcomes. Rehabpro. January 2004.
• Tugman, K., The Vocational Consultants Guide to
  Psychiatric Rehabilitation. Elliott
  Fitzpatrick. Athens, GA. 2002.